Incontinence
An approach to symptom management to guide decision-making in the management of patients with life-threatening illness
Explanation to patient and family
Consider disease-specific palliative therapy
Institute non-pharmacological interventions
Prescribe appropriate first-line treatment
Consider adjuvant/second-line treatment
At all stages of management consider
Definition
The involuntary loss of urine, which may cause hygienic, physical and/or social problems
Assessment
Urinary Incontinence is a common and distressing symptom at the end of life, affecting the patients’ lives physically, psycho-socially, socially and sexually. Thus, leading to isolation from family and friends as they try to maintain their own personal hygiene and fear losing their dignity in public.
Continence difficulties may be:
- Caused by an underlying condition
- Triggered by medication
- Associated with reduced mobility or cognitive decline
- Present before the onset of the disease
It is essential to determine the cause and identify those patients where the incontinence is due to an inability to reach the toilet in time.
- Urge incontinence signs and symptoms: sudden, strong desire to void, frequency, loss of moderate to large volume of urine, may be unable to reach the toilet in time, nocturia and/or enuresis usually present. Timed voiding and anticholinergics may be helpful.
- Stress incontinence signs and symptoms: leakage with physical activity (coughing, laughing, lifting etc.), small volume of urine, intermittent dribbling, unable to reach toilet following urge to void. Common in multiparous women with poor urethral support and reduced pelvic floor tone. Support prosthesis such as a ring pessary or urethral inserts may be useful.
- Overflow incontinence: urethral over-activity (anatomical obstruction e.g. BPH (Benign Prostatic Hyperplasia), neoplasm) , bladder under-activity (neuropathy – sacral plexus damage or spinal cord/cauda equina compression, opioids), strain to void, sense of incomplete emptying, lower abdominal pain/fullness. Clinically able to distinguish the distended palpable bladder much more easily than the floppy large bladder. Permanent catheterisation is probably unavoidable, however in less terminal patients, intermittent catheterisation, urethral stenting or surgical interventions should be explored. Referral to a urologist is essential in this instance.
- Functional incontinence: inability to reach the toilet in time due to physical, psychological or environmental impediment.
- Fistula: (abnormal communication between two hollow viscera or viscera and skin) causes relate commonly to radiotherapy, colonic malignancy/local tumour invasion or diverticulitis/inflammatory bowel disease. Cystoscopy, contrast cystography or intestinal barium studies will demonstrate the fistula. The following options should be explored: surgical removal of bowel section/excision and repair, bypass surgery or urinary diversion. The advantages and disadvantages of these interventions should be discussed with the patient.
- Vesicoenteric or rectal: common symptoms are pneumaturia, foul urine odour, faecal matter in the urine and recurrent urinary tract infection (UTI). Treatment options depend on the patient’s fitness and willingness to live with a stoma.
- Vesicovaginal: continuous leakage of urine from the bladder into the vagina and must be distinguished from total urethral incontinence.
- Total urethral incontinence: local incompetence of the urethral sphincter (direct tumour invasion or surgery) or central loss of sphincter control (confusion and dementia) leads to uncontrollable loss of urine. Regular toileting, a female urethral catheter or a male sheath catheter in men, may be tried.
Explanation to patient and family
Incontinence is a devastating blow to dignity and should therefore be managed with great sensitivity. Inability to maintain personal hygiene and malodour will lead to social isolation and this will need appropriate discussion. Continence care is usually aimed at promoting continence but the approach may change in end-of-life care. Care should be based on the patient’s wishes and preferences and aimed at maintaining comfort and dignity and relieving symptoms.
Correct reversible factors
- Diet (excessive volume of liquid late in the day, caffeinated drinks, alcohol)
- Medical conditions (delirium, infection, restricted mobility, impaction, diabetes)
- Medication (carbamazepine, diuretics, lithium, opioids (overflow))
- Physical/environmental barriers
- Odour: Metronidazole 400mg tds may reduce odour from anaerobic infections. Buchu douching or cleansing is found to be useful. Charcoal dressings and masking the smell is not always effective.
Consider disease-specific palliative therapy
Discussed in relation to the identified problems, as management is varied.
Institute non-pharmacological interventions
- Patient education (fluid restriction in the afternoon and evening)
- Lifestyle modification (e.g. commode, decreased caffeine)
- Behavioural modification: timed voiding
- Invasive devices (e.g. catheter, stent) FG 16 is the smallest useful size for adults, sialastic catheters are most appropriate and should be changed 6 weekly.
- External collection of urine (nappies, Paul’s tubing) – meticulous skin protection with barrier creams such as zinc and castor oil is mandatory.
- Intermittent self-catheterisation used together with an absorbent pad
Prescribe appropriate first-line treatment
- Infection: MCS and appropriate antibiotic
- Barrier preparation to protect the skin (Zinc and castor oil/ Vaseline/ Fissan paste)
- Relieve constipation (see GIT guidelines)
- Review medication for medicines which may be exacerbating the problem
Consider adjuvant/second-line treatment
- Desmopressin (EDL secondary list) 10-40 micrograms intranasally or 100-400 micrograms orally at night. (contraindicated in cardiac insufficiency, peripheral or cerebral vascular disease, hypertension, renal impairment)
- Palliative surgery, chemo- or radiotherapy to relieve spinal cord compression or reduce size of local mass
Review assessment and management
At all stages of management consider
Involvement of interdisciplinary team.
Sensitive counselling is important, physiotherapy may provide some relief from incontinence especially in the early stages.
Referral to appropriate service/more experienced clinician
Urologist of gynaecologist.