Continence - What are we aiming for?!!

Continence - What are we aiming for?!! Dr Tammy Angel

Why is it important? INCONTINENCE Curable! IS NOT A NORMAL PART OF AGEING

QOL • Occupational • Physical • Social • Psychological • Sexual • Domestic

Topics for today.. • What’s normal? • What are the NICE guidelines for each types of incontinence? • Local services and National initiatives • Working example..

Normal? Bladder stores and voids Usually sense ‘urge’ to PU at 2-300mls At socially convenient time and place Reflex relaxation of external sphincter Bladder muscle contracts

Types of incontinence • Stress • Urge • Overflow • Functional • Cognitive/neurological/psychiatric • Mixed

NICE Rx UI • At initial ax-SUI/UUI/ Mixed • Hx is suffficient to inform non invasive 1st line Rx options • (3 day) bladder diaries • Invasive Ix NOT recommended before conservative Rx

Stress incontinence.. • Pelvic floor exercises .. ‘of at least 3 months duration’ • Digital ax PFM contraction- at least 8 contractions tds - consider electrical stimulation/ biofeedback for pts unable to actively contract PF • Duloxetine : ‘Not be routinely used 2nd line, may be offered as alternative to surgical Rx’ • Urodynamics +/- surgical intervention (TVT TOT; injectables colposuspension)

Urge incontinence • Rx UTI’s and stop unnecessary diuretics • OAB : Caffeine reduction and Bladder retraining .. ‘at least 6 weeks’ • Anticholinergics ‘ non-proprietary oxybutynin due to cost effectiveness rather efficacy - if not tolerated tolterodine; solifenacin, trospium • Intravaginal oestrogens for atrophy • Botulinium toxin A (willing to self catheterise); sacral nerve stimulation; augmentation cystoplasty; urinary diversion • intravesical oxybutynin,

Overflow incontinence • Clear bowels • Alphablockers eg tamsulosin • Stop anticholinergics • Intermittent self catheterisation • ?prostatic surgery

Functional incontinence • Physiotherapy • Move closer to toilet Neuropsych REGULAR TOILETTING

How should we assess pts - history? MEDICAL COMORBITIES MOBILITY DRUGS PSxH BOWELS INFECTION COGNITION

Examination: Abdomen/ Pelvis Perineal/ cough Rectal Post micturition bladder scan +/- Neuro/ Gait Investigation Fluid volume charts Urinalysis/ MSU Creatinine PSA AXR +/- USS Renal tracts Continence Assessment

Hemel initiatives.. Weekly ward round : “the dry, the wet and the catheterised”! Rolling Educational Programme for All Assessment of patients in Day Hospital and RAU Management Algorithims and care plan Participation in National Continence Audit Local Catheter Audit + Identify HCA + Trained on each ward + Weekly screening--> see referrals + rationalise pad usage

Bleep 1725

Shape of new service

Service Objectives.. • Patients identified, comprehensively assessed, and appropriately managed • Patients receive written information about their condition • Better follow up for patients • Improve transfer of information into community • Promote education

My interpretation.. Community Continence Advisors

Working example • 70 yr old woman; • C/O: severe urgency, UI, nocturnal frequency..needs radioactive iodine! • PMH : ‘CCF’, HT, OA awaiting THR • DH: BFZ, Frusemide, Diltiazem, doxazosin tramadol • PSH: N and no previous ix

Further hx and ix • O/E: well in self , mild SOA, • abdo NAD, PV N, PR loaded • Urinalysis = clear • Bladder scan when ‘desperate’ = 60 mls and PMRV = 0 mls • WHAT NEXT?…

Assessment.. • Overactive bladder with small capacity • Exacerbated by diuretics, • Reduced mobility due to OA, • SOA ? Diltiazem/Gravity/RVF • Constipation

Plan and outcome • Stopped BFZ, doxazosin • Frusemide at 5pm then fluid restrict • Detrusitol XL 4 mg od • Bladder retraining exercises – holding on • Senna and docusate • Leg elevation during the day • DRY!!.. Rx radioiodine

Conclusions Dispel 2 urban myths: • Incontinence is not normal for age • It is curable… A continence nurse specialist will dramatically improve quality of service and community integration!

THANK YOU FOR YOUR ATTENTION

Any questions ?

Continence - What are we aiming for?!!