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Chapter
5: Controlling urinary incontinence
Achieving control
of urinary continence is the key to achieving an independent lifestyle.
A wide range of interventions and resources exist to assist in the
successful management of urinary incontinence.
This chapter provides the clinician with an introduction to management
principles, some resources and also outlines the roles of specialist
clinics in the management of incontinence (for issues of faecal
incontinence, see Chapter 6).
Key issues for clinicians
• Incontinence impacts on all aspects of life. Successful
management of incontinence overcomes a major barrier to personal
and social independence.
• Incontinence is best managed in conjunction with a specialist
continence clinic.
• Most young people and adults with spina bifida will have
already established incontinence management. The role of the general
practitioner is largely one of review and detection of management
problems. These can then be referred to a specialist clinic if
indicated.
• Conservative management is the first step to incontinence
management.
• Clean intermittent catheterisation is a common and important
component of incontinence management. Clinicians need to familiarise
themselves with this procedure.
• Incontinence management procedures need to be reviewed
after a urinary tract infection.
• Persistent changes in continence patterns should be referred
to a specialist clinic.
• There are surgical interventions available to assist incontinence
management if conservative measures fail. These are organised
through specialist clinics.
• Clinicians need to be aware of the existence of possible
latex allergies when treating patients with spina bifida.
Incontinence impacts on all aspects of daily
living
Incontinence can prevent people with spina bifida
from achieving full participation in all aspects of life, such as
work, education, personal relationships and general activities of
daily living. In addition, incontinence is almost a taboo subject,
viewed by many in society as a weakness and a source of shame.
Impact on self esteem
Incontinence also brings many other daily problems,
such as changing beds, and clothes, washing soiled linen and clothing,
constant worry over possible episodes of incontinence, embarrassment,
shame at soiling in public, accusing looks from teachers, work colleagues
and the general public - all leading to difficulty in coping with
daily life.
These issues can lead to poor self esteem, contributing to a sense
of frustration, guilt, fear and isolation, making coping even more
difficult.
Continence control - the incontinence management
team
There are many resources and health care providers
available for achieving successful continence control and GPs can
help link people with spina bifida to these specialist clinics.
Not only are there specialist teams to help children, but clinics
for young people and adults with spina bifida also exist (see Chapter
9 Organisations and further resources).
Clinicians having problems identifying nearby adult treatment centres
may be able to obtain their location by contacting a paediatric
treatment centre.
Overview of bladder and urinary tract management
Common approaches to the management of bladder
and other urinary tract problems in spina bifida involve a combination
of the following:
• conservative management including pharmacological agents
• surgical intervention
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continence control needs to be managed under the direction of
a urologist and continence clinic. Many adults with spina bifida
are unaware of these resources, and GPs can greatly improve
quality of life by referring patients to these specialist centres.
The GP remains a key player in this team as the first point
of contact for patients. |
The following procedures are described to familiarise clinicians
with common approaches to bladder management. Treatment should only
be initiated under the direction of a urologist, or a spina bifida
or continence clinic.
Conservative management
Conservative management of bladder problems usually involves a combination
of clean intermittent catheterisation (CIC) and the use of pharmacological
agents.
Establishing a routine
The key to successful incontinence control is to establish incontinence
management procedures as part of every day living. When incontinence
control becomes a problem, the aim is then to re-establish these
routines.
Clinicians need to be aware of differences in incontinence control
for those affected by spina bifida. For example, the experience
of many GPs will be in children with normal bladders. Incontinence
control issues in spina bifida are wider than this; incontinence
occurs within the context of a neurogenic bladder, and is an ongoing
issue for all ages for people with spina bifida.
Timing is the key
The key to successful control of urinary incontinence in spina bifida
is bladder timing. Only a small number of people with spina bifida
will be successfully bladder trained, but successful timing can
be achieved in a majority of cases.
Successful bladder timing - that is, the regular emptying of the
bladder - allows the person to have control and confidently participate
in school, work and other areas of life.
Establishing routines and regular practice is the first step to
achieving effective incontinence control. When routines become upset,
this pattern can be used as a target to get habits back into line.
Intermittent catheterisation
Intermittent catheterisation of the bladder
allows it to empty, in order to prevent retention, reflux and other
complications, and to help control incontinence.
Practice
points
In the presence of nerve damage, the person
with spina bifida may have difficulty telling the difference
between a full bladder and a full bowel.
Sensation from the muscle wall of overstretched bladders are
weak or nonexistent.
Detruser sphincter dyssynergia can either cause a rush of urine
flow when the sphincter does open,
and usually occurs at inconvenient times, or may just cause
a dribble when the urinary bladder pressure rises above a certain
level.
Swimming and drinking will increase the urine output.
Anxiety, shocks and excitement can precipitate episodes of incontinence.
Sensations such as abdominal ‘pain’ can be confused
with bladder or bowel fullness sensations.
Incontinence control routines can be upset by intermittent infections,
procedures, illnesses and other precipitating factors. |
This simple, clean (not sterile) procedure
repeated a few times a day allows control of the timing of bladder
emptying.
Clean intermittent catheterisation aims to achieve continence by
emptying the bladder at scheduled intervals, as well as reducing
residual urine volume in order to prevent infection and bladder
overstretching.
Intermittent catheterisation gives the person with spina bifida
a great deal of control over incontinence, and while achieving good
technique may take some practice, the effort is well worthwhile
and achievable. Self catheterisation requires good hand to eye coordination.
Self catheterisation gives a young person or adult increased self
esteem through increased independence. Self catheterisation also
means that the person can attend school or work unassisted.
Young people may have issues with compliance with self catheterisation
and the clinician may need to check that techniques are being followed.
This may involve referral to a specialist incontinence management
team.
Reviewing catheterisation techniques
Many young people and adults with spina
bifida will have already been using intermittent catheterisation
for many years. In this case, the role of GPs seeing adult patients
for the first time may not be to teach intermittent catheterisation,
but to review technique, check that the appropriate catheter type
is being used and refer to specialist centres as needed.
Catheterisation techniques should be especially reviewed when there
is a change in continence pattern or after a urinary tract infection.
Reusable catheters should be replaced with single use catheters
in the presence of a urinary tract infection.
Intermittent catheterisation
Catheterisation aims to empty the bladder
to protect renal function and to achieve social independence through
prevention of incontinence. Catheterisation is a simple, clean method
of inserting a plastic catheter several times a day to drain urine
(Tables 5, 6).
Catheterisation and the toilet
Catheterisation is usually performed in
the toilet, as using this socially acceptable place helps to normalise
the process of urination. That is, the toilet is the same place
used for urination as that for continent people. Toilets are always
available, even if they need to be cleaned afterwards. When the
catheter is correctly inserted, the person can hear the urine fall
into the water and knows that the catheter has been inserted sufficiently
and into the correct orifice (for women). In addition, sitting upright
gives better drainage and maximises the chances of using the correct
method to withdraw the catheter - that is, downwards.
Catheterisation should be performed before emptying the bowels.
The self catheterisation routine-
the role of specialist clinics
Self catheterisation is a complex technique
and is best taught by specialist continence clinics. These clinics
can adapt teaching to suit each individual according to their special
needs and gender. However, clinicians can keep copies of any instructions
issued to the patient to assist in reinforcing key messages directed
by the specialist clinics.
While establishing catheterisation techniques is often done with
the assistance of a specialist continence team, the GP can assist
by going through the patient’s technique to ensure that each
step is performed correctly. A checklist has been prepared to help
clinicians ensure the basic technique is adequate (Table 7), but
more detailed information and assistance is available from the specialist
continence team.
General practitioners with any questions can contact the continence
nurses or other health professionals of continence clinics for further
assistance.
Latex allergies
Be aware that allergies to latex are more
common in people with spina bifida than for the general population.
Reactions can vary between mild reactions to severe anaphylactic
shock. Clinicians need to remain alert to this possibility and to
refer to specialist clinics for advice if the situation arises.
Case
study: Betty is a 26 year old woman with incontinence.
She has overflow incontinence, and although
using a CIC routine - which she has been using for many years
- needs continence pads. Wheelchair bound, she has oscillated
between living at home and independently, the major issue being
a constant smell of urine, although she is desensitised to the
smell. She lacks confidence and seems to have given up any ambition
of work. Apparently very disorganised, when you talk to her
about the urine smell issue she becomes distraught and angry.
You encourage her to attend an adult spina bifida clinic and
a continence nurse.
The nurse reports that she is using inappropriate pads, wrong
sized catheter, and is not catheterising frequently enough.
With some planning assistance and assigning a friend who will
tell her if she smells, her continence control is much improved.
Establishing control involves keeping the catheterisation routine
constant. Each time it is performed, it should be identical.
Not only does this maximise effectiveness of the procedure,
but decreases risk of urinary tract infection. |
Pharmacological agents
Under the direction of a specialist, pharmacological
agents can be an important adjunct to intermittent catheterisation.
Common agents include anticholinergics such as propantheline bromide;
musculotropics including oxybutinin, and antimuscarinics
such as tolterodine.
Adverse effects
These agents can cause adverse central
nervous system effects that can interfere with cognition, which
may in turn complicate any deficits already present (see Chapter
2 The impact of hydrocephalus and other CNS conditions on case management.)
These agents may also contribute to constipation, which can contribute
to faecal incontinence.
Surgical intervention
Surgical intervention for the management
of incontinence is an important option for people with spina bifida
where other procedures, such as CIC are not feasible.
Table
5: Clean intermittent catheterisation - instructions for males
Equipment required:
Catheter, cleansing solution, lubricating
gel, cottonwool balls or wipes.
Procedure:
1. Wash hands with soap and water.
2. Lubricate the catheter.
3. Retract foreskin if not circumcised and wash the tip of the
penis using a cleansing solution.
4. Hold penis upright and gently insert the catheter into the
urethra. If resistance is met part way, rotate the catheter
or use gentle but firm pressure
on the catheter until the muscle relaxes. It may also help to
take some deep, slow breaths.
5. When the urine flow has stopped, advance the catheter one
more inch to ensure the bladder is fully empty.
6. Slowly remove the catheter liberally.
7. Males with foreskins should always push the foreskin back
again after the procedure.
8. Put on clean pad.
9. Wash hands with soap and water after washing and packing
away equipment and cleaning toilet seat. |
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Table
6: Clean intermittent catheterisation - instructions for females
Equipment required:
Catheter, clean pad and clothing, lubricating
gel, washer, cottonwool swabs or wipes.
Procedure:
1. Wash hands with soap and water.
2. Lubricate catheter liberally.
3. Sit well back on the toilet.
4. Clean the vulva with 3 swabs from front to back.
5. Wipe hands.
6. With one hand, hold the labia apart and see or feel for the
clitoris.
7. With the other hand, place the tip of the catheter behind
the clitoris. Insert gently until it enters the urethra. Gently
push in until the urine flow begins.
8. When the urine has stopped flowing, slowly pull out the catheter.
9. Wash hands and put on clean pad.
10. Wash hands with soap and water after washing and packing
away equipment. |
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| Ensure
that patients using reusable clean catheters for intermittent
catheterisation move to single use disposable catheters during
a urinary tract infection. After the infection has resolved,
patients can then start using a new, reusable catheter. |
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Table 7: Checklist for reviewing self
catheterisation technique
• Have copies of any patient instructions
for procedures included in their medical history file to
help check some of the following key issues.
• Patients may benefit from visual instruction using
illustrations rather than verbal instruction if learning
difficulties are present
• The routine must be kept the same each time.
• Ensure that hands are washed at each point indicated
in the procedure.
• Ensure that the catheter is lubricated liberally.
• Instruct patients to be careful to prevent contamination
from clothes. This may be done by folding the clothes upwards
and using a peg to keep clothes
fastened and away from genital area.
• The bladder must be fully drained as incomplete emptying
is a common cause of urinary tract infections. To do this:
• •
• •
• -the full length of
the catheter must be held below the level of the bladder
throughout the entire procedure
• •
• •
• -gentle pressure is
applied to the lower abdomen after the flow of urine has
been stopped.
• The flow of urine is sometimes stopped if the sphincter
closes on the catheter giving the impression of complete
bladder emptying. This may be indicated by resistance when
removing the catheter and by lower urine output than expected
during drainage. In this case, repeat the procedure in 1/2–1
hour.
• Assess bowel habits: constipation may cause partial
urethral obstruction.
• Associate bladder emptying to the daily routine,
such as when getting up in the morning, after meal times
and before going to bed.
• Also review techniques and any instructions given
for cleaning catheters.
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In addition, there are many urological reasons for
surgical interventions, all of which impact upon the control of
continence.
The decision to proceed with surgical intervention for the control
of urinary incontinence in spina bifida is a highly complex area.
Indications for surgical intervention of the urinary tract in spina
bifida include:
• persistent high urinary storage pressure
• upper urinary tract deterioration
• gross vesicoureteric reflux
• incontinence due to intrinsic sphincter deficiency (ISD)
High bladder pressure
As discussed previously, the most common
neurogenic pattern in spina bifida is an areflexic bladder with
a nonfunctional sphincter. This can lead to complications of the
upper renal tract and can be a major source of morbidity and mortality.
This often results in high bladder pressure due to urinary retention.
High bladder pressure can result in long term urinary sphincter
damage.
Surgical management of high bladder
pressure may involve a variety of techniques
There is a wide range of surgical options
to manage incontinence in spina bifida that can be tailored to each
individual. These procedures are constantly improving and increasing
in technical sophistication, emphasising the importance of patients
receiving regular urological surveillance.
Overview of common surgical procedures
The following is a list of common urological
procedures used in spina bifida, and their more common indications.
Vesicostomy
Vesicostomy is indicated in the presence
of persistent hydronephrosis and recurrent urinary tract infection
when the bladder continually fails to empty. This simple procedure
which involves making a stoma from the bladder to the skin surface
to allow drainage, has a low revision rate and allows normal growth
and maturation. Vesicostomies are often performed as temporary procedures
in children.
Urinary diversion
Urinary diversion can be used when augmentation
procedures fail to work for many physical, personal and social reasons.
Procedures include illeal and colon conduits and cutaneous ureterostomy.
Augmentation cystoplasty
Augmentation cystoplasty involves surgically
configuring a segment of bowel to augment the bladder and correct
vesicoureteric reflux. When deciding upon an augmentation cystoplasty,
issues to consider include which part of the bowel to use, eg. illeum,
stomach, sigmoid colon or other section. Complications can result
from the mucosa of the segment of origin, such as haematuria when
using gastric lining or mucus production when using sigmoid colon.
Ureteric augmentation uses distended hydronephrotic ureters, if
present, to augment the bladder. Other complications of augmentation
can include perforation, infection, mucus production, calculi and
the potential for malignancy, although this risk is small.
Catheterisable stomas
Catheterisable stomas may be useful in
patients unable to perform intermittent catheterisation due to lack
of dexterity or being wheelchair-bound. They also have a place when
a urethra is unavailable, perhaps due to the presence of a stricture
or a fistula.
The Mitrofanoff procedure is the formation of an abdominal stoma
which is then connected to the bladder with a tubal structure such
as the appendix. Urine is then drained by passing intermittent urinary
catheters. For example, in the Mitrofanoff appendix procedure, the
stoma is created from the appendix and part of the caecum with intact
blood supply. The tip of the appendix is then buried through the
bladder wall to create a passageway for urine. Other structures
have also been used, including: gastric tissue; fallopian tubes;
ureters; and other parts of the bowel.
Transurethral injection
Transurethral injection therapy is used
to treat intrinsic sphincter deficiency and involves the submucosal
injection of a biocompatible substance such as collagen or silicon.
The efficacy of treatment depends largely upon selecting patients
with suitable urodynamic patterns.3 The advantage of submucosal
injection is the low morbidity, but its main disadvantage is the
lack of long term data on most of the substances.
Slings
Pubovaginal slings are the treatment of
choice for females with intrinsic sphincter deficiency although
there is also a role for the procedure in some males Suburethral
slings use a variety of techniques and materials and many series
have included long term follow up. Native tissue, such as the use
of an autologous tendon, appears to be associated with less morbidity
than using synthetic materials. Patients must be monitored postoperatively
to ensure bladder emptying takes place and that there is no upper
tract deterioration.
Artificial urinary sphincters
Artificial urinary sphincters are implanted
silicon devices that close the urethra. The artificial sphincter
may be placed at the bladder neck or bulbar urethra. The artificial
sphincter is regarded as the main treatment option for male patients
with intrinsic sphincter deficiency. Again, post-operative monitoring
is essential to ensure that urinary tract complications due to the
elevated bladder pressure associated with an artificial sphincter
are prevented.
Circumcision
Circumcision may be indicated in males,
especially when in the presence of recurrent urinary tract infections
where circumcision can sometimes reduce their frequency.
Reversal of surgical procedures
Young people and adults with spina bifida
may present having had a particular surgical technique for incontinence
at some stage in the past but without a recent urological review.
Many options are not permanent, and can be changed to suit the needs
of the person at that time in their life.
In light of surgical advances there may now be further options for
these patients to explore. Some of these patients may want to try
alternate continence procedures and may want to have their surgery
reversed. Referral to a specialist centre enables patients to explore
the advantages and disadvantages of each of these procedures.
Case
history: John is 22 years old
He is a highly motivated man who had a urinary
diversion procedure when he was a toddler. He has managed with
a bag for years, but is beginning to realise that he has missed
out on many activities such as swimming and travelling and confides
that he ‘can’t imagine a sexual relationship with
the bag present’.
He has also heard at a spina bifida meeting that his kidneys
may be affected. He is amazed when you advise him that this
procedure may be reversable, with him starting a clean intermittent
catheterisation routine. Enthusiastic to find out more, he is
eager to visit the adult spina bifida clinic. |
Reversal of urinary diversion (also called undiversion)
may be an option in motivated patients when physical considerations
allow. Patients may have had urinary diversion procedures in the
past when these procedures were a more common first line treatment
and may now wish to take advantage of more recently introduced augmentation
procedures. Reversal of diversion allows the introduction of a clean
intermittent catheterisation regimen that may be more beneficial
for renal function and promotes independence. This process can offer
significant benefits to a select group of patients, but motivation
needs to be high as it involves considerable preoperative preparation
and a high degree of postoperative compliance to ensure effective
clean intermittent catheterisation.
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