GUIDELINES FOR THE MANAGEMENT OF URINARY INCONTINENCE IN THE PALLIATIVE CARE SETTING 43.1 GENERAL PRINCIPLES Urinary continence can be defined as the ability to store urine in the bladder and to excrete voluntarily where and when it is socially acceptable. 1 Urinary incontinence has a significant impact upon an individual s dignity and self-esteem, thus a sensitive approach to assessment is required. 2 Urinary incontinence has a significant impact on the patient-carer relationship and is one of the main reasons for admission to residential care. Carers should be involved in assessment where appropriate. 3, 4 Symptoms of urinary incontinence can be improved with basic nursing interventions in up to 3, 4, 5 70% of patients. Constipation, urinary tract infections and urinary retention are the most common reversible causes of urinary incontinence. The symptoms of urinary incontinence may not be related to the palliative diagnosis and may be longstanding. 2 Social stigma, embarrassment and lack of knowledge of health care professionals can all be barriers to recognising and treating urinary incontinence. 3, 5 Urethral catheters can be a useful containment measure but both the risks and benefits need to be considered when they are used (see Table 43.1). 6 Table 43.1. Considerations when using a urinary catheter. 6 Blockage / bypass Bladder spasms Confidence Dignity Impact on independence Source of infection 43.2 GUIDELINES 43.2.1 Assessment All patients should be asked about the presence of urinary symptoms on initial assessment and any findings should be documented. 3, 7 [Level 3] Assessment of urinary incontinence should focus on identifying reversible causes such as constipation, infection and urinary retention. See Figure 43.1 for further details. 3, 8, 9 [Level 3] Medications which may be contributing to incontinence should be reviewed. 3 [Level 4] The verbal history from the patient can be confirmed by use of a bladder frequency chart completed for a minimum of 3 days (see Table 43.2). 8 [Level 4] If the patient is too unwell or declines a further continence assessment this should be documented in the notes. 3, 7 [Level 4]
Table 43.2. Continence history Duration Changes in severity Dysuria Frequency Haematuria Hesitancy Leakage Nocturia / nocturnal enuresis Poor stream Straining Urgency 43.2.2 Management When discussing the management of urinary incontinence with the patient and their carer, realistic goals should be set and included in their care plan. 10 [Level 1-] Reversible causes should be treated e.g. constipation, urinary tract infection, urinary retention. 3, 8, 9 [Level 3] Where there is impaired mobility, manual dexterity or cognition consider referral to a physiotherapist and occupational therapist. 3 [Level 4] For patients with a good performance status, consider referral to specialist continence services following initial assessment and management. They may provide pelvic floor exercise training and advice on referral for urodynamics. 3 [Level 4] Where there is no evidence of infection, constipation or urinary retention, or where there is intractable incontinence, containment products should be used. These include pads, male and female urinals, bed-pans, conveens and catheters. Referral to the district nursing team or community continence assessment team may be required to ensure a supply of containment measures. 3 [Level 4] The use of catheters should be documented in the case notes, and the care plan communicated when the patient is admitted, transferred or discharged. Table 43.3 lists the documentation required. 3, 11 [Level 4] Table 43.3. Documentation required at catheterisation. 3, 11 [Level 4] Date, time, location and name of professional performing procedure Reason for catheterisation Consent Type and size of catheter Residual volume Date for reassessment Date for renewal
Figure 43.1 The assessment of urinary incontinence. 3, 7-9, 12 [Level 4] Patient reports symptoms of urinary incontinence. Bowel assessment including PR examination to assess faecal loading. Treat constipation Patient is constipated Yes No Urinalysis Send MSSU for C&S. Commence antibiotics (as per guidelines) Dipstick +ve for leucocytes +/- nitrites No Assess residual volume with bladder scan or in-out catheterisation. <200ml Continence history and bladder chart. Yes >200ml Review for causes of urinary retention. e.g. faecal impaction, UTI, drugs, spinal cord compression, urethral obstruction.treat where appropriate
43.3 STANDARDS 1. A basic knowledge of continence is required to perform a continence assessment. All units should have a continence link nurse who will attend continence study days and cascade training to the team. 3, 4 [Grade D] 2. All patients should be asked about the presence of symptoms of urinary incontinence at initial assessment. This should be documented in the case notes. 3, 4, 7, 9 [Grade D] 3. All patients with urinary incontinence should be assessed for constipation and urinary tract infection excluded. 3, 11 [Grade D] 4. All patients with urinary incontinence should be offered a basic continence assessment. This should be documented in the case notes. 3, 7, 12 [Grade D] 5. The use of catheters should be documented in the case notes, and the care plan communicated when the patient is admitted, transferred or discharged (see Table 43.3). 3, 11, 12 [Grade D] 43.4 REFERENCES 1. Feneley RCL. Urinary Incontinence: Prevalence and Needs. Br J Urol 1979: 51: 493-496. 2. Kellerher C. Quality of life and urinary incontinence. Baillieres Clin Obstet Gynaecol 2000: 14(2): 363-379. 3. Department of Health. Good Practice in Continence Services. 2000. Available from: http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguida nce/dh_4005851. [Last accessed 21 June 2009] 4. Royal College of Physicians. Incontinence causes, management and provision of services. Report of Working Party. London, RCP. 1995 5. O Brien J, Austin M, Sethi P, O Boyle P. Urinary incontinence: prevalence, need for treatment and effectiveness of intervention by nurse. Br Med J 1991; 303: 1308-1312. 6. Faisinger R, Bruera E. Palliative care round: Urinary catheters in palliative care. J Pain Symptom Manage 1991; 6: 449-451. 7. Royal College of Physicians. National Audit of Continence Care for Older People. Report of the National Audit of Continence: Continence Care for Older People in England, Wales and Northern Ireland. Health Care for Older People Programme. London, 2005. 8. Colley W. Charting New Waters. Nurs Times 1996: 92(24); 59-61. 9. Bayliss V, Salter L, Berry L. Pathways for evidence based continence care. Nurs Stand 2004: 19(9); 45-54. 10. Williams S, Perry S, Brittain KR. Patient s goal setting: a useful assessment tool? Clin Effect Nurs 2001: 5; 10-17. 11. National Institute for Health and Clinical Excellence. Urinary incontinence. The management of urinary incontinence in women. 2006. Available from: http://www.nice.org.uk/cg40. [Last accessed 21 June 2009] 12. Merseyside and Cheshire Palliative Care Network Audit Group. Management of Urinary Incontinence in a Palliative Care Setting. Expert Consensus. November 2006.
43.5 CONTRIBUTORS Lead Contributors Dr C Finnegan Specialist Registrar in Palliative Medicine St Johns Hospice Wirral Miss A Doyle Team Leader Woodlands Hospice Liverpool External Reviewers Dr A Capewell Consultant Physician/ Clinical Director Care of the Elderly St Helens and Knowsley Teaching Hospitals NHS Trust Prescot Merseyside
Dr F Twomey Consultant in Palliative Medicine Manchester Royal Infirmary / St Anns Hospice Manchester Dr H Hugel Consultant in Palliative Medicine Aintree University Hospitals NHS Foundation Trust Liverpool