Introduction
Continence is the ability to pass urine/faeces voluntarily, in a socially acceptable place.
Incontinence of urine or faeces affects 3 million adults and half a million children in the UK. Some causes of incontinence are curable, and for most people with incontinence medical intervention can improve their quality of life. However, less than a third of affected people seek medical help, through reluctance to discuss their problem, or fear that nothing can be done.
Incontinence of Urine.
The ability to control bladder function is normally acquired in childhood, with most children being dry both day and night by the age of 5 years. However one in 20 still have nocturnal enuresis (bedwetting) at age 5, and one in 100 adults continue to have enuresis.
Incontinence of urine can occur in any age group. The four main types are stress, urge, overflow, and functional incontinence.
Stress incontinence usually occurs in women, as a result of weakness of muscles in the pelvis or at the neck of the bladder. It results in leakage of urine in certain specific situations, such as when coughing, laughing or sneezing, or during exercise. It tends to affect older women, particularly after the menopause, and the tendency may be increased by stresses to the pelvic muscles during childbirth.
Urge incontinence is the result of instability of the bladder muscles, and is more common in older people. It results in an urgent need to pass urine at frequent intervals both day and night; incontinence results if there is delay in reaching a toilet or suitable receptacle. Urge incontinence may result from a problem with the bladder itself, or it may arise as a consequence of damage to the central nervous system and nerves controlling bladder function.
Overflow incontinence occurs when the bladder fails to empty completely; urine builds up and in the end overflows resulting in either intermittent or continuous dribbling. It may result from obstruction to the neck of the bladder, as occurs in older men due to enlargement of the prostate gland at the base of the bladder. It may also result from disease or injury of the brain or spinal cord, eg multiple sclerosis, traumatic paraplegia, which affects the nerves that control bladder function. In such cases there may be complete lack of control of bladder function.
Functional incontinence is the passing of urine in inappropriate places. It may be a result of varying degrees of immobility, for example making it difficult or impossible for the person to reach a toilet or to manage their clothing. It may also be the result of disturbed mental function, eg. dementia, severe behaviour disorders, in which normal awareness of acceptable social behaviour is lost.
Incontinence of Faeces.
The most common cause of bowel incontinence, particularly in elderly people, is constipation with "overflow", leakage of bowel mucus around a mass of hard faeces which has built up in the rectum (lower bowel).
True incontinence of faeces may occur as a result of damage to the anal muscle which controls bowel actions; this may occur for example as a result of a difficult childbirth. It may also occur with disorders causing diarrhoea, where leakage can occur if a toilet cannot be reached in time to meet an urgent need to defaecate. The most common causes of prolonged diarrhoea are bowel disorders such as ulcerative colitis, Crohn's disease or irritable bowel syndrome; and psychological disorders resulting in excessive or inappropriate use of laxatives.
Care Needs.
If the underlying cause of incontinence of urine or faeces cannot be cured or controlled by medical intervention, the person with incontinence will need to manage the condition by the use of aids such as incontinence pads and waterproof pants; or of appliances such as penile sheaths or catheters (tubes passed into the bladder at intervals to drain it of urine).
Younger people with normal manual dexterity and mental function will usually be able to manage aids and appliances without help; but elderly people, particularly if they have impaired manual dexterity, may need help.
People, particularly those in older age groups, with impaired mobility, who have difficulty in and out of bed or a chair, or whose walking ability is substantially reduced, may need help to reach a toilet or commode in time to prevent incontinence. Since urge incontinence can occur both by day and at night, help may be needed on more than one occasion during the night. Help may also be necessary to change wet or soiled garments or bedclothes. People who are incontinent and whose mobility is impaired may be more prone to pressure sores if left in wet clothing or bedding. Frequent changes of clothing and bed linen may be required if the condition cannot be otherwise managed.
Persons with severe behaviour disorder or dementia will need to be reminded to use the toilet or commode at regular intervals to avoid incontinence. They are also likely to require help to manage incontinence aids.
Children with enuresis (persistent bed-wetting) are usually unaware of the wet bed. Most parents accept enuresis as a normal phenomenon, and it is not common practice to change children's bedding during the night on a regular basis. Some parents become intolerant of their children's wetting, and may suggest incorrectly that it is deliberate, or a result of laziness. This attitude can lead to secondary emotional disturbances in the child.
Mobility Considerations.
People with incontinence may claim to have restricted mobility because of their need to be within easy reach of a toilet. This is not however a condition which of itself causes any difficulty with walking.
Duration of Needs.
Where care needs arise as a result of incontinence, the underlying condition is unlikely to improve with time.
Further Evidence.
People, particularly in younger age groups, who rely on incontinence aids or appliances may receive help and advice from a specially trained community nurse, from whom further information can be sought.
