Incontinence is a loss of bladder or bowel control that causes you to pass urine or faeces when you do not mean to. This can range from a small ‘dribble’ now and then to large floods of urine or a complete bowel movement.

Urinary Incontinence can have devastating effects on the woman, detrimentally affecting her level of activity and psychosocial state, leading to depression and withdrawal from social settings.

Characterisation of the type of incontinence can help to elucidate the underlying aetiology and help to guide management. While urinary incontinence may be the result of several underlying and overlapping pathophysiological mechanisms, this topic focuses on non-neurogenic stress and urgency incontinence.

It is estimated that 3 million people in the UK are regularly incontinent. It is possible that this number is higher as many people don’t tell anyone about their problem. Incontinence is often preventable and treatable. Anyone can experience incontinence, although it is more common in older people. It affects far more women than men and is thought to occur in 1 in 5 women over the age of 40. Many people think it is an inevitable part of ageing but there are several forms of treatment available.

Continence is an important contributor to a person’s health and well-being at any stage of life. It is also a key factor in the use of health resources for the following reasons:

In older people, incontinence and associated bladder and bowel disorders may be associated with physical problems such as skin breakdown, falls, urine infection and catheter associated urinary tract infection which in turn often causes confusion. Confusion and its sequelae often result in an acute hospital admission.

Incontinence or the use of urinary catheters significantly increases the level of dependency in frail older people. This may delay discharge from hospital or initiate a move into a residential or nursing care setting.

This guidance helps to ensure people receive excellent continence care; consideration should be given to:

• Early assessment by an appropriately trained professional, allowing a patient centred and cost-effective care pathway to be followed.

• After assessment, the use of containment products, medication and the level of intervention can be triaged and escalated.

• Containment with the use of pads or catheters may be the only realistic option for some people, but this management has associated problems.

The expected standards in the initial identification, assessment, and nursing management of patients with urinary incontinence in acute assessment unit, medical wards and elderly care units/wards.

The requirements to consider specialist referral in conjunction with the medical team.

1.1 Stress Urinary Incontinence: The sudden leakage of urine caused by an increase in intra-abdominal pressure, e.g., coughing, sneezing, standing up or laughing. This may be associated with obesity and/or postpartum dysfunction.

1.2 Functional Urinary Incontinence: The inability of a usually continent person to reach the toilet in time to avoid unintentional loss of urine.

1.3 Urge Urinary Incontinence: Involuntary passage of passage of urine occurring soon after a sensation of urgency to void.

1.4 Voiding difficulties or overflow incontinence: The involuntary loss of control when a specific bladder capacity is reached; bladder is over distended, and overflow occurs. Symptoms displayed include dribbling, dysuria (painful or difficult urination), frequency and the sensation of fullness with small voiding. This may result in a total inability to pass urine (acute on chronic urinary retention) and is usually caused by a large prostate in men and constipation in women.

2.1 If a new urinary incontinence and a Urinary Tract Infection (UTI) is suspected, a full clinical assessment should be undertaken on all patients to determine if this is the cause of their urinary incontinence.

2.2The routine undertaking of urine dipstick testing to diagnose UTI’s in patients over 65 years of age is no longer considered best practice. Many older people have bacteria present in the bladder/urine (asymptomatic bacteriuria) which produces a positive dipstick test result. This however is not harmful and does not require treatment with antibiotics. Unnecessarily treating asymptomatic bacteriuria in older people is associated with more harm than benefit.

2.3 In patients over 65 years of age where a UTI is suspected, assess if any of the following symptoms are present:

• Localised symptoms of a urine infection, e.g., new onset dysuria, incontinence and/or urgency, suprapubic tenderness if catheterised.

• A temperature of either 38⁰C or <36⁰C or +/- 1.5⁰C from the baseline temperature twice in the past 12 hours.

• Non-specific symptoms of infection e.g. increased confusion, drowsiness, or loss of diabetic control.

• Assess the patient’s risk of sepsis using national Sepsis Guidelines. (NICE 2019). If the sepsis risk is moderate or NEWS score is above the threshold, consider urinary sepsis or pyelonephritis as an alternative diagnosis.

If symptoms and/or signs are present, send as MSU and give antibiotics as per local antimicrobial prescribing guidelines. There is no need to dip the urine.

3.1 All older people admitted who are over 65 years should have the continence section of the nursing Adult Patient Assessment booklet completed. If the patient has new incontinence then they should be fully assessed and have the appropriate interventions, as per the Urinary Incontinence in Older People Algorithm.

A nursing continence assessment is required to be completed within 24-48 hours of admission into hospital to ascertain level of continence.

The document is on Epic and appears as below:

Continence Assessment

The above will enable the clinical team to identify the type of continence and put in an action plan for the patient, please see guidance below.

A 48-hour diary is required to be completed to enable ascertain level of continence (below). This should be documented on Epic.

Continence Diary

Where the completed questionnaire indicates a specific problem, the following interventions should be considered

4.1 Appropriate follow-up must be provided for all patients discharged with urinary incontinence. The follow up may be with a specialist service within the acute hospital or it may be with District Nursing services, GP or Nursing and Residential Home teams. Please complete a community nurse referral on Epic and email to the relevant teams for continence assessment in the community.

4.2 Ensure arrangements have been made for further provision of appropriate containment products (pads, urinary sheaths, or urinary bottles) for use on discharge. This can be through referral to District Nursing teams for a continence assessment for provision of pads. Some products are not provided by the local continence teams and patients will have to purchase them privately, e.g., urinary bottles.

1. NICE (2019) Urinary incontinence and pelvic organ prolapse in women: management https://www.nice.org.uk/Guidance/NG123
2. NICE (2021) Urinary incontinence in women. Quality standard [QS77]. 2021 Nov. Available from: https://www.nice.org.uk/guidance/qs77
3. Public Health England (2020) Diagnosis of Urinary Tract Infections https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/927195/UTI_diagnostic_flowchart_NICE-October_2020-FINAL.pdf
4. Wagg A, Gibson W, Ostaszkiewicz J, Johnson T, Markland A, Palmer A, Palmer M.H., Kuchel G, Szonyi G, Kirschner-Hermanns R (2015) Urinary Incontinence in Frail Elderly Persons: Report from the 5th International consultation on incontinence Neurourology and Urodynamics 34:398-406

To complete the Community Nurse referral for a Continence Assessment on Epic

• Create a ‘New Note’

• Note ‘Type’ – Discharge Referral

• Note ‘Specialty’ – state relevant specialty

• Note ‘Smart Text’ – FHFT Referral to Community Nursing

• Complete all sections and provide additional information if required, suggestions for which are noted on the Community Nurse referral form

If the referrer has the relevant access, a PDF copy of the referral can be created using the ‘Referral Release’ function on Epic.

If the referrer does not have access to the ‘Referral Release’ function a copy of the referral will need to be printed, scanned then emailed to the respective community hubs.

Referrals are to be sent to:

Berkshire: integratedhub@berkshire.nhs.uk Berkshire Integrated Hub – 0300 365 1234

Buckinghamshire: buc-tr.communityspa@nhs.net Community Care Co-ordination Team (CCCT) – 0800 177 7789

This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

This guideline is for use in Frimley Health Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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