Continence

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Continence

• by
• Dr. R.G. Cooper
• Senior Lecturer
• Division of Physiology
• School of Health and Policy Studies

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Urinary tract

• The normal urinary tract is made up of two
  kidneys, two ureters, a bladder and a urethra.
  Each ureter enters the bladder at an angle that
  creates a tunnel through the bladder wall muscle.
  As the bladder fills and during emptying, this
  tunnel prevents any urine from backing up from
  the bladder into the ureter. By the end of
  urination, nearly all the urine has passed from
  the bladder and out of the body through the
  urethra.

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Bladder

• Introduction
• Kidneys receive blood via the renal arteries
  blood leaves via the renal veins.
• Urine is excreted from the kidneys.
• The bladder stretches (can hold 700-1000mL
  urine).
• Urine is passed out via the urethra.

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Muscle layers of the bladder

• mucosa
• submucosa
• muscularis

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Functions of the bladder

• Storing urine for extended periods.
• Storage function increases the sanitary
  conditions of an animal's living area.
• Bladder is a sphere.

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Functions continued

• Detrusor muscle in the wall and urothelium lining
  the interior surface allows bladder to stretch.
• Emptying of the bladder is controlled by the
  micturition reflex via the parasympathetic
  system.
• Voluntary control.

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Urination

• First urge to urinate is when bladder volume is
  150 mL.
• External sphincter muscle relaxes, detrusor
  muscle contracts.
• Urine passes out of urethra.
• Partial blockage, e.g. STDs, makes urination
  very painful.

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Altered Bladder Function

• Diseases of the bladder
• Cystitis (inflammation of bladder).
• Cancer. bladder cancer
• Urinary bladder dysfunction.
• Urinary incontinence.
• Haematuria, or presence of blood in the urine
  (bladder cancer, or bladder and kidney stones).

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Prostate

• The prostate is a muscular, walnut-sized gland
  that surrounds part of the urethra.
• Part of the male reproductive system.
• Secretes seminal fluid.
• Muscles in the prostate propel semen through the
  urethra.

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Composition of prostate

• Main prostatic glands - lead to prostatic cancer
• Submucosal glands - lead to benign prostatic
  hyperplasia
• Mucosal glands - lead to benign prostatic
  hyperplasia

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Anatomy and Physiology of Prostate

• The prostate is located directly beneath the
  bladder and in front of the rectum.
• The upper portion of the urethra passes through
  the prostate.
• If the gland becomes enlarged it can obstruct the
  passage of fluid through the urethra.
• Can cause discomfort and embarrassment.

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Diseases of the Prostate

• The two main benign diseases of the prostate are
  prostatitis and Prostatic Hyperplasia (BPH).
• Main malignant (cancerous) disease of the
  prostate is prostate cancer.
• Prostate cancer is leading cause of death.

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Prostatic hyperplasia

• Enlargement of inner zone of prostate.
• Blocks the urethra.
• Difficulty during urination.
• Bladder infections.

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Prostate cancer

• The risk for developing prostate cancer highest
  in men gt70 years.
• Early prostate cancer is found during a routine
  digital rectal examination (DRE).
• A family history of prostate cancer increases the
  risk.

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Symptoms of prostatic disease

• Blood in the urine or semen.
• Frequent urination, especially at night
• Inability to urinate.
• Nagging pain or stiffness in the back, hips,
  upper thighs, or pelvis.
• Painful ejaculation.
• Pain or burning during urination (dysuria).
• Weak or interrupted urinary flow.

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Pelvic floor

• Pelvic floor muscles
• They support the bladder, uterus, vagina and
  bowel.
• They form a muscular and elastic floor across the
  bottom of the pelvis.
• The muscles relax to empty the bladder and bowel.
  
• Stretching of these muscles during childbirth and
  straining with constipation sometimes causes
  muscle weakening.

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Signs of weak pelvic floor musclesLeaking
urine, coughing, not getting to the toilet in
time, tampons won't stay in place, vaginal or
anal flatus (wind), bulging felt at the vaginal
opening (prolapse), difficulty emptying the
bowel, and vaginal heaviness.
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Pelvic floor muscles

• Pubic bone in front to the bottom of the
  backbone.
• Mostly muscle fibres of levator ani.
• Connective tissue.

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Rectum and pelvic floor

• Rectum and pelvic floor muscles are to prevent
  incontinence (loss of control) and to allow
  defecation to occur.
• The rectum is very elastic, which allows it to
  store faeces prior to a bowel movement.
• Sensory nerves detect the filling of the rectum.

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This sensation of rectal filling enables us
to consciously or unconsciously squeeze the
external anal sphincter to prevent incontinence
until we can reach a toilet. These sensory
nerves are also involved in reflexes that let the
sphincter muscles relax during a bowel
movement.
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Faecal incontinence

• Faecal incontinence means involuntary passage of
  faeces in someone gt 4 years.
• Causes are (1) weakness of the anal sphincters
  muscles (2) loss of sensation for rectal
  fullness (3) constipation and (4) stiff rectum.
  

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Senile Vaginitis

• Senile vaginitis is an inflammation or irritation
  of the vagina caused by thinning and shrinking of
  the tissues of the vagina and decreased
  lubrication of the vaginal walls.
• This is due to a lack of oestrogen. This
  condition is common in post menopausal women.
• See the next slide of inflamed vaginal cells.

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Causes of senile vaginitis

• Decrease in oestrogen.
• May occur in younger women who have had surgery
  to remove their ovaries.
• Immediately after childbirth or while
  breastfeeding, since oestrogen levels are lower
  at these times.

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Risk factors in senile vaginitis

• Menopause.
• Decreased ovarian functioning.
• Radiation therapy.
• Chemotherapy.
• Immune disorder.
• Medications containing anti oestrogen properties.
• Smoking.

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Symptoms of senile vaginitis

• Vaginal soreness - an itching or burning
  sensation.
• Slight vaginal discharge.
• Burning on urination.
• Light bleeding after intercourse.
• Painful sexual intercourse.

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What other factors can cause incontinence

• MEDICATION, e.g. Frusemide a diuretic which
  encourages fluid loss from the body.
• Anti-epileptics, e.g. Carbamazepine often used
  for generalised tonic- clonic seizures
• Anti-depressants, e.g. Amitriptyline may cause
  constipation and urinary retention thus leading
  to incontinence
• Anti-psychotics, e.g. Zolepine (Depot) and
  Respiridone are known to have side effects of
  urinary incontinence. Clozapine produces side
  effects including urinary incontinence and
  constipation.
• Anti-bacterial, e.g. penicillin may cause
  diarrhoea

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Continued

• Stimulants - Caffeine, Tea, Coffee, Coca- cola
  and alcohol all have a diuretic effect.
•  
• Bladder infection - Infection causes the bladder
  to become very irritated, urine is passed
  frequently as the stretch receptors are activated
• Constipation - A bulky mass in the bowel may
  press on the bladder resulting in incontinence
•  
• Mobility - A very mild bladder problem may become
  severe incontinence for an immobile person

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Continued

• Dexterity - Dyspraxia, arthritis, Hemi-plegia or
  other conditions associated with poor muscle
  control may mean that clothing removal is
  difficult. This may just tip the balance between
  continence and incontinence where clothing is not
  removed in time.
• Degenerative conditions - People with Dementia or
  other conditions where cognitive function is poor
  may no longer recognise the urge to pass urine or
  identify that the toilet is the socially
  acceptable place to empty bowel and/or bladder.

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Promoting continence

• Incontinence imposes a considerable financial
  burden on the Health Service with approximately
  50 million spent on disposable incontinence
  products between 150- 180 per patient per
  year.
• To be continent you must be able to-
• 1. Recognise the need to pass urine or faeces.
• 2. Identify the correct place, i.e. toilet or
  commode.
• 3. Reach the correct place before the bladder or
  bowel is emptied.
• 4. Pass urine or Faeces when you get there.

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Actions that the health professional can use to
help promote continence

• Pelvic Floor exercises.
• Bladder retraining.
• Adequate toileting.
• Individualised toileting programmes.
• Treat any underlying disorders.
• Adequate fluid intake.
• Drug therapy.
• Surgery.
• Consider any improvements that might be made to
  the environment.

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Case study
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George is 42 years old and lives with his mother,
Ethel who is 79. Ethel has always cared for
George as she sees it as her duty. George likes
to go out walking no matter what the weather for
at least one hour a day and Ethel has always
supported this although more recently Ethel's
health has meant that she is finding this
increasingly difficult. George attends a day
centre 3 days a week but the day centre cannot
always guarantee they can 'walk' George due to
staffing ratio's to service users. George uses a
combination of Makaton signs and some verbal
communication in single words format e.g.. drink,
dinner, walk etc. George has been receiving
support from the community learning disability
nurse during the last six months. The aim being
to introduce George to a short breaks service in
anticipation of Ethel going into hospital for
some long needed surgery on her knee. This has
been going well and George seems to have enjoyed
the short breaks and Ethel has expressed benefits
to having a break. George has always opened his
bowels on the toilet. Ethel puts him on first
thing in the morning after his breakfast and
after his evening meal. George will open his
bowels at least once a day at either of these
times and sometimes twice. George is not usually
urine continent. He will sometimes pass urine at
the same time as opening his bowels but this is
hit and miss. Ethel has always maintained George
in pads as she worries there may be accidents.
George enjoys a good varied diet and always shows
pleasure when food is being prepared or presented
to him.George will be going into short breaks for
three weeks in a month's time when Ethel goes for
her long awaited knee surgery. At a recent Mdt
meeting it was suggested this may be an
opportunity to review George's urinary
incontinence and Ethel has reluctantly agreed
this may have benefits for George. As far as
Ethel is aware no one has ever questioned or
considered George's urinary incontinence,
although he did have a toileting programme when
he was at School but Ethel wasn't able to support
it during holidays.  
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Questions for the case study   How might you
summarise the problems of promoting full
continence in George?   What clues do you get
from the case history that George may be capable
of becoming fully continent?   What stimuli might
George have that his bladder is getting full? How
might he be able to ignore these?   What
considerations need to be taken in preparing an
individualised toileting programme for George?