Incontinence is a common problem, with urinary incontinence being more common than faecal. There are a number of different types of urinary incontinence, which are described below.

The main types of bladder problems are:

• urgency urinary incontinence - an involuntary leakage of urinary accompanied or followed by the feeling of urgent need to void
• stress urinary incontinence - an involuntary leakage of urine on exertion, such as coughing, sneezing or exercising
• mixed urinary incontinence - both urgency and stress symptoms
• nocturnal enuresis - involuntary loss of urine during sleep
• leakage following passing urine and continuous urinary leakage - these are symptomatic forms of incontinence
• overactive bladder - (may not be incontinent) characterised by the storage symptoms of urgency, usually with frequency and nocturia (waking to pass urine)
• neurogenic bladder dysfunction - urinary bladder problems due to disease or injury of the central nervous system or peripheral nerves involved in the control of urination. 

Stress incontinence

Stress incontinence is the involuntary loss of a small amount of urine when pressure increases in the abdomen, for example when coughing or sneezing. It is a problem that predominantly affects women.

What causes stress incontinence?

Weakness may be caused by a variety of factors, including:

• surgery - particularly in men following prostate surgery
• pregnancy and childbirth
• obesity
• menopause
• chronic cough
• chronic constipation.

What can be done?

Pelvic floor exercises, vaginal weights, surgery, oestrogen, washables pants or disposable containment product as a last resort.

Passive incontinence

When a person feels no urge to open their bladder or bowels. They are unaware that the bladder or rectum is full and ready to be emptied and cannot consciously control their bladder or bowel movements, therefore urine or stools can pass without their knowledge.

Additional causes of incontinence in men

• Prostatitis - an inflammation of the prostate gland
• Prostate cancer - this is treatable when identified early.

The prostate is approximately the size of a walnut and surrounds the urethra just below the bladder. Its main function is to secrete prostate fluid, one of the components of semen. The muscles of the prostate gland also help propel this fluid into the urethra during ejaculation.

Men can suffer from prostatitis, an inflammation of the prostate gland.

Symptoms can include:

• pain in pelvis, genitals, lower back and buttocks
• frequency of urination
• pain when urinating
• difficulty urinating and “stop-start” peeing
• pain when ejaculating
• tiredness, aching joints, chills and fever.

It is important to consult a responsible clinician if these symptoms are experienced.

Benign Prostatic Hyperplasia (BPH)

The prostate gland often enlarges as men get older and, in some cases, it can become problematic. As the prostate enlarges it may cause narrowing of the urethra. The bladder then needs to contract harder to squeeze urine out. This can cause the bladder to weaken and lose the ability to empty completely, causing overflow incontinence.

BPH can be managed with lifestyle changes, medication and sometimes surgery.

Symptoms:

• the need to urinate more frequently, often at night
• difficulty starting to pass urine
• weak flow
• feeling the bladder has not emptied
• taking a long time to urinate.

Normally a General Practitioner will take a full history of symptoms and perform an examination. They will request a prostate specific antigen (PSA) blood test and carry out a digital rectal examination.

Other factors affecting both men and women 

Functional incontinence is where a person is usually aware of the need to urinate, but for one or more physical or psychological reasons they are unable to get to the toilet.

People with dementia may be aware of the need to go to the toilet but may not be able to express this need. There could be a noticeable change in behaviour, such as agitation or restlessness. They may have forgotten where the toilet is or be in unfamiliar surroundings.

Physical problems such as poor eyesight, mobility or dexterity can all lead to difficulty accessing the toilet. Fear of falling, depression and anxiety can also be factors, as well as environmental factors, such as poor lighting, low chairs, stairs or steps and unusual surroundings. Inadequate toilet facilities or a person's fear of using them can also contribute to someone being incontinent.

Outflow obstruction

This is where the bladder neck is restricted. It is more common in men because as they age the prostate gland naturally enlarges, restricting the urethra and making it harder to pass urine. It may also enlarge as a result of cancer.

Other causes of outflow obstruction include urethral strictures and chronic constipation.

Symptoms of outflow obstruction include:

• passing small, frequent amounts of urine
• hesitancy in starting to pass urine
• poor urine flow
• post micturition (post urination) dribble.

Detrusor underactivity

This is where the bladder muscle is underactive and does not contract properly to effectively pass urine and empty. The bladder will stretch and potentially retain large volumes of urine.

It is caused by damage to the nerves supplying the bladder or to the lower spinal cord. It is usually experienced by people with a spinal injury and neurological conditions, such as multiple sclerosis and diabetic neuropathy.

Symptoms of detrusor hypoactivity include:

• a lack of bladder sensation
• an ability to go long periods of time without passing urine
• overflow incontinence - if the bladder is overfull and can’t fully empty.

In both types of voiding difficulties people may experience frequent urinary tract infections.

Surgery

• having surgery on the lower abdomen can cause the bladder to tilt leading to incontinence or damage to the sphincter.

Pregnancy and childbirth

• it is common for women to experience incontinence during pregnancy and following childbirth.

Excess weight

• excess weight causes pressure on the bladder and makes incontinence worse.

Stress incontinence

Overactive bladder (Urgency)

A person with overactive bladder may not have incontinence but have symptoms that significantly affect their quality of life.

Symptoms of overactive bladder include:

• frequency - needing to pass urine frequently
• urgency - an urgent need to pass urine; at times the person may not reach the toilet in time and be incontinent
• nocturia - waking during the night to use the toilet.

What causes an overactive bladder?

• increase in age
• diuretics, anxiety
• post menopause
• faecal impaction
• diabetes
• irritation to the bladder i.e. stones
• urinary tract infection (UTI)
• fluids and some medications.

What can be done?

• limit caffeine, alcohol and carbonated drinks, bladder retraining, antimuscarinics.

Nocturnal Polyuria

Nocturnal Polyuria is when you produce too much urine overnight. It is defined as passing more than one third of your 24-hour urine output at night.

Causes?

• heart failure
• medication
• sleep apnoea
• drinking too much before bedtime.

What can be done?

• adjusting diet and fluid intake
• elevation of swollen legs during the day
• increase exercise
• diuretic
• nasal or tablet antidiuretic hormone.

Urinary Tract Infections (UTI’s) 

Urinary Tract Infections (UTI’s) Ruling out a urinary tract infection is a key part of a continence assessment. A urinary tract infection can cause urinary frequency and urgency which can lead to incontinence. If the urinary tract infection is diagnosed and treated, the incontinence symptoms may resolve. Smelly or cloudy urine alone, are not signs of a urinary tract infection, but may indicate the patient is dehydrated.

UTI's can affect different parts of your urinary tract. They are divided into three types: 

• lower urinary tract infection (LUTI)
• upper urinary tract infection (UUTI)
• Catheter Acquired Urinary Tract Infection (CAUTI).

Each is diagnosed by a clinical assessment including baseline patient observations.

We will look at each type of infection and then at risks associated with misdiagnosing UTI’s by using urinalysis sticks inappropriately, linked to recent learning about ‘Asymptomatic Bacteriuria’.

Lower Urinary Tract Infections (LUTI's)

LUTI’s affect your bladder (cystitis) and or your urethra (urethritis.)

Symptoms of a lower urinary tract infection include:

• needing to pass urine urgently or more frequently than usual
• pain or a burning sensation when passing urine
• blood in your urine
• pain in lower abdomen
• feeling tired and unwell
• new onset or worsening incontinence
• increased voiding at night.

Spotting symptoms 

UTI symptoms may be difficult to spot in people with dementia.

Patients can seek advice from NHS 111.

The NHS will advise a patient to seek non-urgent advice from their GP if:

• they are a man with symptoms of a UTI
• they are pregnant and have symptoms of a UTI
• a child has symptoms of a UTI
• they are caring for someone elderly who may have a UTI
• they have not had a UTI before
• they have blood in their urine
• their symptoms do not improve within a few days
• their symptoms come back after treatment
• if a patient has symptoms of a sexually transmitted infection (STI), they can also get treatment from a sexual health clinic.

Upper Urinary Tract Infections (UUTI’s)

UUTIs affect your kidneys leading to Pyelonephritis. Patients with an upper urinary tract infection are normally unwell. The common symptoms are listed below. It important to learn that these patients may not mention their bladder at all, but often feel nauseous, or are being sick, have a very high temperature and muscles aches.

Symptoms of an upper urinary tract infection may include the same symptoms as LUTI and will include one or more of the following:

• pain in your sides or lower back  
• a very high temperature or you feel hot and shivery
• feel nauseous or are vomiting
• diarrhoea in older people
• changes in behaviour such as severe confusion or agitation.

These symptoms suggest a kidney infection, which can be serious if it's not treated. Urgent assessment should be sought for these patients e.g. by ringing 111.

Asymptomatic bacteriuria 

Bacteriuria is not a disease. The human body needs bacteria known as normal flora, as a key part of the body’s defences against infection and because of their influence on nutrition.

Bacteriuria can be described as the presence of bacteria in urine when seen under a microscope. We all have some level of bacteria in our urine at all times.

Asymptomatic bacteriuria can be described as the presence of bacteria in urine, when seen under a microscope in a urine sample taken from a patient without any typical symptoms of lower or upper urinary tract infections. This means there is bacteria in the urine, but the patient has no signs or symptoms of a urinary tract infection and therefore does not need any treatment with anti-biotics.

Symptomatic bacteriuria is the presence of a significant amount of bacteriuria in urine when counted under a microscope, from a patient showing more than one of the signs and symptoms of a lower or upper urinary tract infection.

Bacteriuria in the urine is uncommon in people under 65 years but increases in those over 65 years. Bacteriuria is more common in some populations of institutionalised women, for example those living in residential or nursing homes and in people with long term indwelling urinary catheters.

Urinalysis detects the presence of bacteria in the urine by detecting Leucocytes which are white blood cells produced by the body to fight bacteria and Nitrates which are enzymes produced by bacteria.

In the past, health care professionals have used urinalysis and results from urine samples sent for microscopy to diagnose UTI’s. If they found leucocytes and nitrates in patient groups, we now know to have asymptomatic bacteriuria as a normal process, antibiotics would be prescribed for the patient, even though they did not have any signs or symptoms of a urinary tract infection.

The National Institute for Health and care Excellence (NICE) and the Scottish Intercollegiate Guidelines Network (SIGN) now recommended that urinalysis is NOT used to diagnose a urinary tract infection in these groups of patients. Instead a diagnosis must be made purely on a clinical assessment of signs and symptoms.

Urinalysis is still useful as part of a holistic assessment for UTI in adults under the age of 65.

Urinary tract infection (UTI) is the second most common clinical reason for anti-biotics to be prescribed in the UK. The overuse of antibiotics can lead to patient’s having unwanted side effects such as diarrhoea, loss of appetite, thrush infections and could lead to them contracting Clostridium Difficile Infection (CDI) or methicillin resistant Staphylococcus aureus (MRSA) infection. The overuse of antibiotics is also leading to bacteria becoming resistant to them, reducing the number of effective treatments we have.

Further resource: SIGN (2020) Management of suspected bacterial lower urinary tract infection in adult women

Catheter Acquired Urinary Tract Infection (CAUTI) 

100% of patients with an indwelling catheter have bacteriuria therefore urinalysis should never be used to diagnose a CAUTI for a patient with an indwelling catheter or if they use intermittent catheters. These patients should be diagnosed by a holistic assessment including baseline observations, based on their clinical signs and symptoms. The catheter provides a focus for bacterial biofilm formation and most catheterised patients have at least 2 types of bacterial colonisation. Urinary tract infection is the most common hospital acquired infection in the UK, accounting for 23% of all infections and the majority of these are associated with catheters for 8% of hospital acquired bacteraemia (SIGN, 2020).

The longer a patient has a catheter in situ the chance of getting a CAUTI increases.

Always ask:

Does the patient need a catheter? If the answer is NO, ensure plans are made to do a trial without a catheter.

Diagnosis of a CAUTI must always involve assessing for clinical signs and symptoms compatible with a CAUTI.

Dip stick testing of urine must NOT be used to diagnose a CAUTI, because:

• patients with a urinary catheter may have non-visible haematuria due to ongoing trauma of the catheter
• patients with a urinary catheter are likely to have bacterial colonisation of their urine due to the presence of the catheter which would show as leucocytes and nitrates on a urinalysis stick.

Symptoms of a CAUTI include:

• renal angle tenderness or suprapubic pain
• chills/rigors
• new costovertebral tenderness
• new onset delirium
• malaise, or lethargy with no other identified cause
• acute haematuria
• pelvic discomfort.

In those whose catheters have been removed or who are using intermittent catheters:

• dysuria
• urgent or frequent urination
• supra-pubic pain or tenderness.

In patients with spinal cord injury:

• increased spasticity
• autonomic dysreflexia
• fever greater than 37.9°C or 1.5°C above baseline on two occasions during 12 hours.  

If a patient is diagnosed with a CAUTI, a clinical assessment should be made to see if the catheter can be removed. If this is not possible, if the catheter has been in place for more than seven days, ensure the catheter is changed before or as soon as is practicable after antibiotics have been are commenced. Evidence shows this gives the body the best chance of fighting the infection as bacteria will have built up on the old catheter.

Further resource: NICE guidance and information on treatment of a CAUTI: NICE (2018) Urinary tract infection (catheter-associated): antimicrobial prescribing

Urosepsis

What is sepsis?

Sepsis is a life-threatening reaction to an infection. It happens when your immune system overreacts to an infection and starts to damage your body's own tissues and organs. You cannot catch sepsis from another person. Sepsis is sometimes called septicaemia or blood poisoning. If not treated immediately, sepsis can result in organ failure and death. Yet with early diagnosis, it can be treated with antibiotics.

Urosepsis is defined as sepsis whose source is the urogenital tract. It is most often related to an upper urinary tract infection.

Sepsis can initially look like flu, gastroenteritis or a chest infection. There is no one sign, and symptoms present differently between adults and children.

Further resource: Sepsis Trust

How to spot sepsis in an adult

If a person you are caring for looks or feels unwell, doing an early warning score such as the National Early Warning Score (NEWS) can help you to recognise sepsis, raise the alarm quickly to a senior colleague or health care professional and prioritise care so they can be treated within the hour.

Seek medical help urgently if you (or another adult) develop any of these signs:

• Slurred speech or confusion
• Extreme shivering or muscle pain
• Passing no urine (in a day)
• Severe breathlessness
• It feels like you’re going to die
• Skin mottled or discoloured.

Call 999 and just ask: could it be sepsis?

This RCN resource on Sepsis contains guidance on how to assess adults for sepsis and what to do if you think a patient could have sepsis.

Urinalysis 

Urinalysis is a key part of any Continence Assessment. New onset incontinence could be linked to an undiagnosed urinary tract infection. Urinalysis gives us further information to help us assess our patient’s holistically and diagnose and treat type or types of urinary incontinence, and contributing factors such as undiagnosed diabetes, or haematuria suggesting a possible underlying bladder cancer.

Urinalysis as a diagnostic tool for urinary tract infections, should only be used for adults in their own homes, under the age of 65, as the chances of asymptomatic bacteriuria are lower, meaning urinalysis becomes a more useful diagnostic tool.

To Dip or Not to Dip training presentation 

Watch this 15-minute presentation aimed at staff working in residential and nursing care home settings. This is recommended for any health care professionals as the general principles apply to all health care settings. It is a useful summary explaining further the signs and symptoms of a urinary tract infection and the need to ensure patients are diagnosed and treated based on clinical signs and symptoms, reducing the unnecessary prescription of antibiotics.

Further resources 

Royal College of Physicians. National Early Warning Score (NEWS) 2
NICE (2019) Urinary incontinence and pelvic organ prolapse in women: management
NICE (2018) Urinary tract infection (catheter-associated): antimicrobial prescribing
NICE. Guidelines about COVID-19
NICE (2018) Urinary tract infection (lower): antimicrobial prescribing
NICE (2018) Urinary tract infection (recurrent): antimicrobial prescribing
NICE. Urinary tract infections overview
The UK Sepsis Trust. About sepsis
SIGN (2020) Management of suspected bacterial lower urinary tract infection in adult women

Some medications can disrupt the normal process of storing and passing urine or increase the amount of urine produced. However, medication should not be stopped without consulting a GP or consultant.

These are a few examples:

• diuretics (water tablets) such as thiazides and furosemide increase urine production
• opioids such as morphine can interfere with bladder contraction and cause or exacerbate constipation
• Angiotensin Converting Enzyme (ACE) inhibitors such as Ramipril and Captopril are usually used to treat high blood pressure. However, they can cause a cough and worsen stress incontinence
• antidepressants such as citalopram are used to treat mood disorders and can interfere with bladder contraction and make constipation worse
• sedatives such as diazepam and lorazepam can slow the reflexes, affecting the ability to recognise the signal that the bladder is full
• Hormone Replacement Therapy (HRT) – the lower urinary tract is sensitive to the effects of oestrogen and during the menopause levels naturally decline. There is conflicting advice and evidence about whether or not HRT affects bladder control
• alcohol and caffeine are diuretics that can increase urine production. Caffeine can cause irritation of the bladder lining
• nicotine is thought to irritate the detrusor muscle and trigger urge incontinence. Smoking can also cause a cough, which can lead to urine leakage
• ketamine is a drug used medically in anaesthesia and as a pain killer but has been used as a recreational drug due to its hallucinogenic and euphoric properties. In large and repeated doses, it has been found to cause shrinkage and fibrotic changes to the bladder. It can cause frequency, bleeding and pain on passing urine.

Further resources

ICS (2017) Evaluation and treatment of urinary incontinence, pelvic organ prolapse and faecal incontinence 2017
NICE (2019) Urinary incontinence and pelvic organ prolapse in women: management NG123
NICE (2015) Lower urinary tract symptoms in men: management

Bowel incontinence

It is estimated that one in 10 people will be affected by bowel incontinence at some point in their life, although it is more common in women and older people.

Constipation

Straining during bowel movements can weaken the pelvic floor muscles or a full bowel can press against the bladder causing the urgent need to urinate or having to pass urine more frequently.

Constipation can be treated by:

• drinking more water
• eating foods rich in fibre
• doing regular exercise
• practising pelvic floor exercises
• not ignoring the urge to pass stools
• checking the side effects of medications
• iron supplements, calcium supplements and opioids such as morphine can cause constipation
• discussing any concerns with a health care professional and not stopping medication without seeking advice first.

Further resources

RCN Gastroenterology subject guides
RCN (2019) Management of Lower Bowel Dysfunction, including Digital Rectal Examination and Digital Removal of Faeces for more information on bowels and the digestive system.

Urge incontinence

When a person feels the urge to pass faeces but has to rush to make it on time.

Flatus (wind) incontinence

When a person feels the rectum filling, but their body's nerves cannot tell whether it is wind or a stool.

Passive incontinence

When a person feels no urge to open their bowels. They are unaware that the rectum is full and ready to be emptied and cannot consciously control their bowel movements; therefore, stools can pass without their knowledge.

Anal and rectal incontinence

The inability to control the muscles of the rectal canal and anal sphincter. If the nerves are damaged in the rectum control problems and leakage can occur.

Overflow incontinence

The leakage of watery faeces caused by a blockage of hard faeces. This can be mistaken for diarrhoea.

Further resource: RCN (2019) Management of Lower Bowel Dysfunction, including Digital Rectal Examination and Digital Removal of Faeces

Opioids

Opioids such as morphine can interfere with bladder contraction and cause or exacerbate constipation.

Antidepressants

Antidepressants such as citalopram are used to treat mood disorders and can interfere with bladder contraction and make constipation worse.