18

Assessment and Management of Bladder and Bowel Problems

Mandy Wells, Deborah Yarde and Sue Woodward

INTRODUCTION

Urinary and faecal incontinence are prominent features of neurological disorders, such as stroke, multiple sclerosis, spinal cord injuries and inflammation, brain injuries, Parkinson’s disease and dementias, and can have a major impact on psychological and social wellbeing. Due to the complex neurological control of micturition, patients with neurological damage anywhere along the pathway can present with bladder dysfunction. The nature of the presenting problem depends on where in the pathway the nerve damage has occurred. Incontinence has three main aetiological mechanisms: disorders of the bladder and its local spinal network, central nervous system lesions and cognitive disorders, and impaired functional abilities. One might therefore expect a high incidence of incontinence in patients with neurological problems. Depending on the specific neurological condition, prevalence of bladder and bowel problems may affect as many as 75% of patients. NICE guidelines for incontinence in neurological disease are in development.

PHYSIOLOGY OF MICTURITION

The lower urinary tract (LUT), which is comprised of the ureters, bladder and urethra, is innervated by three sets of peripheral nerves. Parasympathetic nerves, which arise at the sacral level of the spinal cord (S2–S4), excite the bladder and relax the urethra. Lumbar sympathetic nerves (T10–L2) inhibit the bladder body and excite the bladder base and urethra. Pudendal nerves control the external urethral sphincter and associated mechanisms of the pelvic floor. All these nerves contain afferent (sensory) axons as well as efferent pathways. The peripheral innervation of the bladder passes through the cauda equina and sacral plexus, but is centrally controlled and coordinated by micturition centres in the pons and the frontal lobe (Fowler, 1999).

Bladder filling

It is thought that tension receptors within the wall of the detrusor muscle are stimulated as it is stretched during bladder filling. More recently it has been suggested that the urothelium releases chemical stimuli when stretched and that this mechanism, rather than tension receptors, stimulates afferent impulses that convey the sensation of bladder fullness (Fry, 2005). Impulses generated during filling are transmitted to the sacral micturition centre (S2–S4) where a reflex response sends an impulse back to the bladder. This results in the detrusor muscle relaxing, so that pressure does not build up within the bladder, and the external urethral sphincter contracting to maintain closure at the bladder neck during filling. As this phase is controlled by sacral spinal reflexes, an individual is unaware of bladder filling at this stage.

During filling, messages are also sent via the spino-thalamic tract towards the brain, but it is not until the bladder is approximately two thirds full that these messages reach the frontal lobes and perception of the sensation of bladder fullness takes place. The bladder is constantly either filling and storing urine, or emptying (micturition). The pontine micturition centre switches between these two states, under the influence of the frontal micturition centre (Fowler, 1999). The storage phase of the urinary bladder can be switched to the voiding phase either involuntarily when bladder capacity is reached, e.g. in babies and some patients with dementia, or voluntarily and influenced by social norms and perception of bladder fullness (Fowler, 1999).

Voiding

Adults normally void approximately 4–500 ml of urine six or seven times daily, depending on fluid intake, although the detrusor muscle can stretch to hold a significantly larger amount than this optimum capacity. Normal micturition requires the detrusor muscle to contract simultaneously with relaxation of the external urethral sphincter to enable a pressure to build up inside the bladder at the same time as the resistance at the bladder neck is reduced (Fry, 2005).

The pontine micturition centre directly excites bladder motor neurones in the sacral cord during micturition causing the detrusor to contract; at the same time, it inhibits the external urethral sphincter motor neurones, causing the sphincter to relax (Blok, 2002). Contraction of the detrusor muscle is maintained until the bladder is emptied fully.

URINARY SYMPTOMS AND INCONTINENCE

The International Continence Society (ICS) defines urinary incontinence as ‘the complaint of any involuntary leakage of urine’ (Abrams et al., 2002). Urinary incontinence is one of a number of lower urinary tract symptoms (LUTS) that may be identified during patient assessments and affects approximately 25% of females and 10% of males among the general population in the UK at any given time. The prevalence among patients with neurological disorders is much higher.

The ICS has attempted to standardise the terminology used by clinicians throughout the world for many years. The terminology is updated periodically as understanding of bladder physiology develops. LUTS have also been defined and divided into either storage, voiding or post-micturition symptoms (Abrams et al., 2002) (Table 18.1).

Table 18.1 Urinary symptoms.

Main problemSymptoms
Storage symptoms
  • Increased daytime frequency: voiding more than eight times per day
  • Nocturia: waking once or more at night to void
  • Urgency: a sudden compelling desire to pass urine which is difficult to defer
  • Urinary incontinence
Voiding symptoms
  • Slow stream: perception that urinary flow is reduced compared to previous performance
  • Splitting or spraying of the urinary stream
  • Intermittent stream: urine flow which stops and starts
  • Hesitancy: difficulty in initiating micturition
  • Straining: muscular effort used to initiate, maintain or improve the urinary stream
  • Terminal dribble: a prolonged final part of micturition, when the flow has slowed
Post-micturition symptoms (experienced immediately after micturition)
  • Feeling of incomplete emptying
  • Post-micturition dribble: the involuntary loss of urine immediately after finishing passing urine

Adapted from Abrams et al., 2002.

There are several distinct types of urinary incontinence (Abrams et al., 2002) (Table 18.2).

Table 18.2 Types of urinary incontinence.

TypeSigns and symptoms
Stress urinary incontinenceLeak on exertion, e.g. coughing, sneezing. Normal voiding pattern
Urge urinary incontinence/overactive bladderMay experience urgency without incontinence (overactive bladder dry) or involuntary leakage associated with urgency (overactive bladder wet)
Frequency
Nocturia
Mixed urinary incontinenceInvoluntary leakage on exertion associated with urgency
Acute/chronic urinary retention (with overflow incontinence)Hesitancy
Slow stream
Straining to void
Patient may or may not have overflow incontinence
Frequency
Significant post-void residual >300 ml
Reflex incontinence/terminal detrusor overactivityIncontinence when the bladder reaches capacity and a single, sustained detrusor contraction empties the bladder fully
Continuous urinary incontinenceComplaint of continuous leakage

NEUROLOGICAL CONDITIONS AND BLADDER DYSFUNCTION

Sometimes the term ‘neurogenic bladder’ is used to describe bladder dysfunction in patients with neurological conditions, but this simply means that the bladder dysfunction is of neurological origin, rather than referring to a specific type of bladder problem. Table 18.3 identifies the type of problem that is likely to be associated with different neurological disorders.

Table 18.3 Common types of urinary incontinence associated with neurological disorders.

Type of bladder dysfunctionCauses
Stress urinary incontinencePregnancy and childbearing, menopause, pelvic floor or urethral sphincter dysfunction (the incontinence is not necessarily related to the neurological condition)
Weak urethral sphincter following spinal damage below T12/L1 affecting the sacral micturition centre
Overactive bladder/urge urinary incontinenceSensory causes: UTI, indwelling urethral catheters, bladder irritants (e.g. caffeine/alcohol)
Motor causes: multiple sclerosis, Parkinson’s disease, head injuries, stroke
Chronic urinary retention – with or without detrusor sphincter dyssynergiaOutflow obstruction: Constipation and faecal impaction, blocked urinary catheter, urethral strictures
Neurogenic causes: multiple sclerosis, spinal cord injury, Guillain–Barré syndrome, other peripheral neuropathies, e.g. diabetic neuropathy
Reflex incontinence/terminal detrusor overactivityDementias, acute confusional disorders, unconscious and sedated patients
Continuous urinary incontinenceUsually due to a vesico-vaginal or vesico-rectal fistula. Rarely seen and not usually due to neurological problems
May occur in multi-system atrophy

Damage to the lower motor neurone

Abrams (2006) identifies that damage to the lower motor neurone causes lost bladder sensation, absent detrusor contractility, reduced bladder compliance, reduced sphincter function, and patients often need to void by straining. Damage to the sacral micturition centre (T12/L1 and below) will result in the detrusor losing its nervous innervation and losing tone. The detrusor does not contract and the bladder cannot empty. This will result in the development of a high residual volume within the bladder and is commonly seen in patients with lower spinal and peripheral lesions.

Damage to the upper motor neurone

Damage to the upper motor neurone causes lost bladder sensation, detrusor overactivity and reduced bladder compliance (Abrams, 2006). Sphincter function is normal during filling but may be overactive during voiding. If the lesion is above T12/L1, the detrusor muscle still receives impulses from the sacral micturition centre, but these are not being coordinated by the brain. The bladder may empty and overactive bladder or detrusor–sphincter dyssynergia can result. Unfortunately for many patients following spinal injury, it cannot be determined on the basis of the neurological level of the injury whether the upper or lower motor neurone is affected (Doherty et al., 2002).

Detrusor–sphincter dyssynergia

This potentially dangerous condition is characterised by lack of coordination of the contractions of the detrusor muscle and external urethral sphincter. Contraction of the detrusor, urethral sphincter and urethral tissue occurs simultaneously resulting in a high pressure building up inside the bladder. This can ultimately cause a retrograde flow of urine up the ureters towards the kidneys, leading to upper urinary tract dilatation and renal impairment (Abrams, 2006).

ASSESSMENT OF BLADDER FUNCTION

Lower urinary tract symptoms cannot be used to make a definitive diagnosis and a thorough bedside assessment is required followed, if necessary, by urodynamic investigations. The nurse has a pivotal role in the recognition, assessment and subsequent management of urinary incontinence (DH, 2000; RCN, 2006). Urinary incontinence is a symptom and should be investigated like any other symptom by taking a detailed history, followed by physical examination and investigations.

There is a lot of stigma and embarrassment for patients surrounding incontinence and they may be reluctant to discuss the problem. Trigger questions (Box 18.1) should be asked during routine assessment to identify patients who might have a bladder or bowel problem (DH, 2003). If a patient responds positively to a trigger question then further in-depth assessment, using appropriate continence assessment tools, is crucial if an accurate diagnosis is to be made. It is important to remember that patients are partners in all care delivery strategies and part of the assessment must include their perception of the problem and their views as to how they would like to see the problem managed.

Box 18.1 Trigger questions

History taking

Ideally a continence assessment tool should be used as this provides an aide memoir for the assessor as well as facilitating accurate documentation, but there are a number of essential components required for every continence assessment (Table 18.4). If no continence specific assessment tools are available within the practice area, the nurse should ensure that all of these components are assessed in detail. After taking the patient’s history in detail, further physical examination is needed and simple investigations may be required (Box 18.2). All of these, except urodynamics are considered an essential part of continence assessment and should be undertaken by nursing staff.

Box 18.2 Examination and investigation of urinary incontinence

Table 18.4 Key components of continence assessment.

Aspect of assessmentQuestions to consider
General health history
  • Identification of reversible conditions that contribute to urinary incontinence (e.g. arthritis, obesity, smoking)
  • Impact of incontinence and how the problem is currently managed
  • Patient’s and carer’s views of treatment options
Past medical, surgical and obstetric historyInclude obstetric history, pelvic surgery, prostatectomy, hysterectomy, diabetes as well as neurological history
Diet and fluid intake
  • Volume and type of fluid intake (note bladder irritant fluids, e.g. caffeine, alcohol)
  • Diet intake (including fibre)
Drug historyCheck for common medications that have effects and side-effects on the bladder (e.g. diuretics, sedatives, anti-cholinergics). Many medications have effects on the bladder that are not routinely recognized
History of incontinence and urinary symptoms
  • Use an assessment checklist as discussed above.
  • Identify most bothersome symptoms
  • Reassessment of patients with neurological disability/disorder is important as their disease progresses
Bowel habitBowel frequency, constipation, faecal incontinence
Functional abilities (including disabilities)
  • Manual dexterity
  • Mobility
  • Cognitive function
Quality of life for patient and family
  • Reducing social contact
  • Impact on relationships
  • Evidence of depression
Environment
  • Access to toilet facilities
  • Laundry facilities

There are a number of internationally recognised valid and reliable tools for the assessment of urinary incontinence, LUTS and impact on quality of life that have been developed by the International Consultation on Incontinence (ICIQ) (Avery et al., 2004). None of the ICIQ questionnaires have been developed specifically for use with patients with a neurological diagnosis, although one is currently in development. Woodward (2006) found a paucity of assessment tools designed for this specific patient group and developed an assessment tool that was found to be valid and reliable and should be considered for the nursing assessment of patients with neurological conditions.

Physical examination and investigations

Physical examination

Physical examination is imperative, but patients are rarely examined in both primary and secondary health care settings (RCP, 2006). Abdominal palpation should be carried out to detect a full bladder or constipation. Perineal skin condition may reveal maceration or excoriation due to sitting in a wet environment. The nurse should also observe for obvious vaginal or rectal prolapse. Pelvic floor assessment should only be undertaken by those with the competence to do so and is beyond the scope of this chapter, but interested readers are referred to Haslam and Laycock (2007). Rectal examination should be performed to check for amount and consistency of stool and to exclude constipation/faecal impaction.

Investigations

Urinalysis

Urinalysis must be undertaken. Haematuria may suggest urinary tract infection (UTI), stones, or cancer, while glucosuria may cause polyuria and exacerbate symptoms. The nurse should use dipsticks that test for leucocytes and nitrites, indicative of UTI. If the urine tests positive for nitrites and leucocytes and the patient is symptomatic, a mid-stream urine should be sent for culture and sensitivities and a course of antibiotics should be prescribed pending results (NICE, 2006).

Post-void residual volume

This should preferably be estimated by using portable ultrasound equipment, but may be assessed by in–out catheterisation. A residual volume up to 100 ml should be considered within normal limits in someone with a neurological disability (Fowler et al., 2009) although some expert clinicians will argue that it can be higher than this. There is no research or even expert consensus on what is the norm in various disease processes or across various age groups.

Frequency–volume charting

Detailed description of the pattern of frequency, volume of voiding, and fluid intake should be obtained through three day frequency–volume chart. Charting will provide more objective information on the number of incontinent episodes, the frequency of micturition and functional bladder capacity. Charting for three days allows for sufficient detail to be collected, while ensuring patient compliance (NICE, 2006).

Urodynamics

Urodynamic investigations aim to reproduce the patient’s symptomatic complaints and to provide a pathophysiological explanation by correlating the patient’s symptoms with the urodynamic finding. Patients are normally treated conservatively and urodynamic investigations are only recommended if this fails (NICE, 2006), as they are invasive and can lead to the patient developing UTI. Such investigations have not been shown to influence outcomes if carried out before initial treatment. Referral for urodynamics should be considered if the diagnosis is uncertain, the patient has failed to respond to conservative management or if there is other complicating co-morbidity.

Urodynamics are more likely to be necessary for patients with neurological disease than for those without. It is usual to perform urodynamic investigations following spinal cord injury after spinal shock has resolved. These baseline urodynamics establish whether there is a detrusor contraction in response to bladder filling and whether or not detrusor–sphincter dyssynergia has developed. They may also be used to assess the effects of disease progression on the lower urinary tract, e.g. for people with multiple sclerosis.

MEDICAL AND NURSING MANAGEMENT OF URINARY INCONTINENCE

Stress incontinence

Stress incontinence is initially treated conservatively with a three month course of pelvic floor exercises. There are no studies that have examined the use of pelvic floor exercises in people with neurological disease, but there is evidence that pelvic floor muscle training is both safe and effective (Hay-Smith and Dumoulin, 2006; NICE, 2006). The exercises should be performed three times a day and may take six months or longer to have their optimal effect (Herbert, 2008). Nurses are ideally placed to teach pelvic floor exercises, but consideration needs to be given to the neurological patient’s sensory perception around the saddle area (perineum) as the patient must be able to feel the pelvic floor move to perform the exercises. If a patient lacks sensation referral to a specialist continence physiotherapist or nurse may be indicated for electrical stimulation and/or biofeedback treatment.

Urge urinary incontinence/overactive bladder

The pathophysiology of the overactive bladder is complex. Increased afferent activity, decreased capacity to process afferent information, decreased suprapontine inhibition, and increased sensitivity to contraction-mediating transmitters are all potential causes of an overactive bladder (Andersson, 2004). Conservative management with bladder training or pharmacological interventions is recommended initially, but other interventions (e.g. botulinum-A toxin injections, sacral nerve stimulation and posterior tibial nerve stimulation) are emerging treatments. Obvious sensory triggers (see Table 18.3) should be treated or eliminated. Some patients experience overactive bladder symptoms in conjunction with voiding inefficiently. It is then important that a regime of intermittent catheterisation (see below: Clean intermittent self catheterisation) is commenced in addition to any other treatment.

Bladder training

Bladder training aims to increase the time interval between voids and there is some evidence that this is effective (Wallace et al., 2004) in the absence of medication, although the mechanism of action is unclear. It is thought that by stretching the detrusor, the effects of unstable contractions may be reduced and bladder capacity increased (Wilson et al., 2002), but effects may be psychological, i.e. patients learn not to empty their bladder ‘just in case’ and develop better bladder habits. To be successful patients need to be cognitively able, motivated and encouraged to perform the technique as it can be uncomfortable and in the short term could increase the number of incontinence episodes. The importance of ongoing support usually from a suitably trained nurse is vital in sustaining the patient through the process. Using a bladder diary during the programme provides a permanent record for baseline and subsequent evaluation of symptoms (Robinson et al., 1996) and provides feedback, aiding motivation.

Fluid manipulation

People with urge incontinence tend to reduce their fluid intake in order to reduce the severity of the symptoms (Pearson and Kelber, 1996). A fluid intake of 1.5–2 litres a day should be maintained and patients should reduce/avoid bladder irritant fluids such as caffeine and alcohol. Although the evidence underpinning fluid manipulation in patients with urinary incontinence is limited there is mounting evidence that the restriction of caffeinated fluids (Tomlinson et al., 1999, Bryant et al., 2002), including fizzy drinks containing caffeine, has a beneficial effect on bladder symptoms. It is important that caffeine is reduced gradually to avoid withdrawal effects such as headache.

Antimuscarinic medication

Antimuscarinic (anticholinergic) drugs are the mainstay treatment for overactive bladder (NICE, 2006). A number of antimuscarinic medications are available, but the most common preparations are oxybutynin and tolterodine. It is generally accepted that no one product is better than the others, although tolterodine has a lower side-effect profile than oxybutynin and sustained-release preparations also cause fewer side-effects (e.g. dry mouth, blurred vision, dyspepsia and constipation) compared with immediate release preparations (Hay-Smith et al., 2005). A more recent Cochrane review has determined that there is no evidence of benefit in using antimuscarinics for patients with multiple sclerosis, and that there was a high rate of adverse events (drug side-effects) in included trials (Nicholas et al., 2009).

Desmopressin (DDAVP)

The use of DDAVP is becoming more frequent for patients who have nocturia, especially in patients with neurological conditions such as multiple sclerosis, although this use is not currently licensed in the UK. DDAVP is a synthetic anti-diuretic hormone which stops the patient from producing urine at night and is most commonly used for children with bedwetting (enuresis) (Glazener and Evans, 2002). It appears to be safe in middle-aged people with neurological conditions and can be beneficial if the patient gets up frequently at night and is losing sleep (Bosma et al., 2005; NICE, 2006). In the older person there is a risk that the patient might develop hyponatraemia and therefore urea, electrolyte and creatinine levels are assessed before and after commencement of treatment.

Botulinum toxin-A (Botox-A)

Botox-A is a potent neurotoxin derived from the bacterium Clostridium botulinum and is known to block the release of acetylcholine and temporarily paralyse any muscle into which it is injected. The precise mechanism of action when injected into the detrusor muscle is unknown (NICE, 2006). Patients who have failed other treatments for their overactive bladder symptoms may be offered Botox-A (Neel et al., 2007; Popat et al., 2005). Intravesical injections are carried out via cystoscopy and last for an average of 6–9 months, so they do have to be repeated if found to alleviate the patient’s symptoms. These repeat injections have so far been found to be safe and have shown beneficial outcomes for the patients (Reitz et al., 2007). This treatment is thought to be promising for refractory urge urinary incontinence, but there is little trial evidence supporting its use (Duthie et al., 2007) and longer term studies have yet to report.

Sacral nerve stimulation (SNS)

SNS, also known as sacral modulation, is an innovative treatment for refractory overactive bladder symptoms. It is thought that appropriate electrical stimulation of the sacral reflex pathway will inhibit the reflex behaviour of the bladder (Abrams et al., 2003). Permanently implantable sacral root stimulators have been developed to stimulate the S3 nerve roots. Patients first undergo a percutaneous nerve evaluation (PNE) in which a needle is inserted through the sacral foramina under local anaesthetic. This is connected to an external pulse generator and left in place for a few days. Those who show satisfactory response to the PNE may then proceed to a permanent implant, with a programmable pulse generator inserted in the abdomen. Approximately two-thirds of patients achieve continence or substantial improvement in symptoms with SNS (Herbison and Arnold, 2009), and the available data show that beneficial effects appear to persist for up to three to five years after implantation.

Percutaneous posterior tibial nerve stimulation (PTNS)

More recently PTNS, in which a current is applied through an acupuncture needle inserted into the posterior tibial nerve just above the ankle, has been researched. The stimulus travels from here to the S3 nerve route and is thought to have a neuromodulation effect on bladder function, although the mechanism of action is not completely understood. To date there is only one published randomised controlled trial of this therapy. This study suggests that the therapy has benefit for many patients whose overactive bladder symptoms have not been relieved by anti-muscarinics (Peters et al., 2009). PTNS is currently the subject of a NICE review, but this guidance is yet to be published.

Urinary retention/overflow incontinence

Urinary retention in patients with neurological disease is normally chronic in nature and it is the resulting overflow incontinence which causes the patient to seek help. Trauma to the spinal cord can cause acute retention and, in the conscious patient, this is easily differentiated from chronic retention by the supra-pubic pain it causes. If acute retention is likely to recur following catheterisation, the treatment regime would be the same as for chronic retention. A residual volume in excess of 100 ml is clinically significant and the bladder needs to be drained (Fowler et al., 2009).

Non-neurological causes (outflow obstruction) must be excluded and treated if possible before concluding that the retention is due to the neurological disorder. The commonest cause of outflow obstruction is constipation and faecal impaction, but other causes include prostatic enlargement, urethral structure, bladder tumours and calculi, which may necessitate a urology referral.

Clean intermittent self-catheterisation (CISC)

CISC is effective in managing urinary retention and is considered to be the gold standard treatment (Winder, 2008). Patients performing CISC have a significantly reduced risk of UTI compared with patients who have indwelling catheters (Turi et al., 2006), preserving the upper urinary tract. Rates of other complications are also lower (Weld and Dmochowski, 2000). Many patients find CISC has a positive impact on quality of life, but it is not completely free of complications, including urethral perforation, stricture formation and neoplastic changes (Pomfret and Winder, 2007). Not all patients will be able to perform CISC due to cognitive impairment, poor manual dexterity or inability to accept the procedure psychologically (Woodward and Rew, 2003) and failure to catheterise frequently enough can lead to incontinence and damage to the upper urinary tract, so careful patient assessment is required. Nurses are ideally placed to introduce the concept to patients and to teach the technique.

The frequency of CISC is individualised and depends on how quickly the residual volume recollects within the bladder, but may be necessary every 3–6 hours. Most catheters in use are single-use hydrophilic/coated catheters, aimed at reducing trauma and easing insertion. There is a lack of reliable evidence to show that these products have benefit over multiple-use or non-coated catheters and further research is urgently required (Moore et al., 2007). CISC is preferably performed by patients themselves, but if this is not possible it may be performed by a relative or care-giver, although again there is a lack of evidence of the impact of this on infection rates (Moore et al., 2007). Some catheters are also available with an integrated drainage bag, which many patients find useful especially when learning the technique. For patients with dexterity problems a variety of handles are also available.

Indwelling urinary catheters

Indwelling urinary catheters should be used only after alternative methods of management have been considered, due to serious risks of long-term complications and infection, which could lead to septicaemia and death (NICE, 2003). Catheter associated UTI accounts for the highest incidence of all health care acquired infections (Pratt et al., 2007) and an evidence-based catheter care bundle has been developed as part of the Saving Lives Campaign (DH, 2007). For patients with neurological conditions either short (<28 days) or long-term (>28 days) urinary catheterisation may be indicated (Table 18.5), although there is no high quality evidence supporting specific catheter policies for adults with neurological bladder disorders (Jamison et al., 2004). Informed consent must always be obtained, if feasible, prior to catheterisation.

Table 18.5 Indications and contraindications for catheterisation.

IndicationsContraindications
  • Urinary retention
  • Accurate fluid balance/acutely ill
  • Assessment/investigations (e.g. urodynamics)
  • Management of incontinence – as a last resort!
  • Competent patient has not consented
  • No permission from medical staff
  • Two failed attempts at catheterisation – refer on to more experienced practitioner

Catheter selection

Catheters should be selected carefully taking into consideration the size, length and duration of catheterisation. Female length catheters (26 cm) can only be used for women, while standard length (43 cm) catheters must be used for male catheterisation. Obese women and those who are very immobile may achieve better drainage with a standard length catheter. Smaller Charriere sizes (10–14 Ch) with a 10 ml balloon are recommended to reduce trauma (NICE, 2003), which can result in inflammation within the urethra and bypassing. Choice of catheter material is influenced by the necessary duration of catheterisation (Table 18.6). There is some evidence that bacteria and encrustation are less likely to adhere to catheters with a hydrogel coating, but there is little evidence of difference in outcomes between coated latex and silicone catheters (NICE, 2003). More recently silver alloy catheters have been introduced and shown to reduce infection in short-term catheterisation (up to one week), after which there is no evidence of significant difference in infection rates (Schumm and Lam, 2008). There is also some suggestion that hydrogel-coated latex catheters are better tolerated than silicone catheters (Jahn et al., 2007) and silicone catheters have a tendency to ‘cuff’ on deflation, which can cause injury on removal (NICE, 2003). However silicone catheters must be used if there is any suggestion of latex allergy.

Table 18.6 Catheter Materials.

Short-term materials
(up to 3 weeks)		Long-term materials
(up to 12 weeks)
  • Latex
  • PTFE coated latex
  • Siliconised latex
  • PVC
  • Silicone elastomer
  • Hydrogel coated latex
  • Silver alloy coated latex
  • 100% silicone
  • Hydrogel coated 100% silicone

Drainage systems

Patients who are given the opportunity will often express a preference for a catheter valve over a drainage bag and there is no evidence of increased infection rates when using a valve (NICE, 2003). However patients must first be assessed for their manual dexterity, cognitive ability and preferences for night-time drainage before using a valve (Medical Devices Agency, 1997). If a valve is unsuitable the catheter is continuously drained through a closed drainage system to reduce infection (Pratt et al., 2007). For mobile patients a leg bag is attached to the catheter and is changed according to the manufacturer’s instructions (normally every 7 days) (NICE, 2003). Each night a larger capacity single-use night bag is attached to the leg bag so that urine drains through one to the other. This night bag is removed in the morning, the urine emptied down a toilet and the bag discarded.

Suprapubic catheterisation

The suprapubic route should be the first choice of route for long-term catheterisation in patients who are wheelchair bound or sexually active. Although initial insertion of a suprapubic catheter is a surgical procedure, sometimes requiring a general rather than local anaesthetic, this route is preferable for women with neurological conditions. Reduced mobility means that they are unable to change position easily when sitting which in turn puts pressure on the catheter possibly causing erosion of the urethra and bladder neck. Access to a suprapubic site is also easier for hygiene purposes (Getliffe, 2003).

Whichever catheter system is being used, nurses must ensure that patients receive information on how to care for the catheter and accessories, identify infection and other catheter related complications and whom to contact if problems occur.

Reflex incontinence

Behavioural methods of management of reflex incontinence can work, such as habit training in which an individual toileting regime is planned to coincide with the patient’s pattern of voiding, but this is not always successful.

Containment

If continence cannot be achieved for people with reflex or other types of incontinence then the urine voided must be contained and skin integrity maintained. Containment may be achieved by utilising products such as urinary sheaths, Bioderm device or pads with pants (reusable and disposable). The same types of pads can be used for the containment of urine and faeces and are funded through health authority budgets and usually provided by community health services. The smallest pad possible that will contain the urine loss should be selected and these should be fitted according to the manufacturer’s instructions. Other urological products (catheters, drainage bags, sheaths) are prescription-only items and may be prescribed by suitably qualified nurses. Sheaths must be correctly measured and fitted according to manufacturers’ instructions, and the Bioderm device can be particularly useful for men with retracted anatomy (Woodward, 2007). Patients and carers must be advised to ensure frequent skin care is maintained and about appropriate use of barrier creams.

PHYSIOLOGY OF DEFECATION

Normal defecation takes place when faeces move through the rectum, distending it and increasing the anorectal angle that is maintained by the puborectalis muscle. The internal anal sphincter which is under autonomic control relaxes, and if it is convenient to evacuate the bowel the external sphincter can be voluntarily relaxed for defecation to take place (Coggrave, 2005). If it is not convenient the external sphincter, which is normally contracted at rest, can voluntarily be contracted further for a short period. This will allow the faeces to move back up in to the rectum and delay defecation until it is more convenient (Emmanuel, 2004).

The desire to defecate is termed ‘call to stool’ and a repeated inhibition of this desire can lead to constipation. It is often at its strongest after a meal, particularly breakfast, or after exercise when the gastrocolic response is at its strongest and peristalsis increases. This reflex reaction in the gut results in mass movement of faeces through the colon (Woodward, 2010). Lack of mobility will delay this action resulting in slow transit constipation, and this is often seen in patients with neurological conditions (Barrett, 2002).

Emptying the bowel should be a painless procedure requiring little or no effort. It is aided by correct positioning on the toilet, i.e. with feet firmly planted on the floor or a stool with the forearms resting on the thighs, and by relaxing the pelvic floor so that it descends. Evacuation of the bowel cannot occur without causing odour and patients should be allowed to do this sitting comfortably on the toilet whenever possible: privacy cannot be over emphasised.

NEUROLOGICAL CONDITIONS AND BOWEL DISORDERS

Faecal incontinence and constipation are common among people with neurological conditions, as a result of cognitive impairment, reduced mobility, loss of control of pelvic floor muscles, loss of ano-rectal and pelvic floor sensation, or altered colonic motility. Neurogenic bowel refers to constipation or faecal incontinence associated with a neurological condition (Wiesel and Bell, 2004). Box 18.3 identifies the prevalence of bowel problems associated with common neurological conditions. Treatment of one problem can often precipitate another (Coggrave et al., 2006).

Box 18.3 Prevalence of bowel problems

Adapted from Wiesel and Bell, 2004.

Constipation

Defecation normally occurs between three times a day and once every three days. Constipation is defined as ‘unsatisfactory defecation characterised by infrequent stools, difficult stool passage, or both. Difficult stool passage includes straining, a sense of difficulty passing stool, incomplete evacuation, hard/lumpy stools, prolonged time to stool, or need for manual manoeuvres to pass stool’ (Brandt et al., 2005). Chronic constipation is further defined as the presence of these symptoms for at least six months and affects many patients with neurological disease.

Two sub-types of constipation have been distinguished: slow transit constipation and functional outlet obstruction (evacuation disorder). Impairment of rectal emptying is thought to be due to abnormal use of a normal pelvic floor. During straining, the puborectalis muscle contracts instead of relaxing and the anal canal remains closed, preventing defecation. It has also been suggested that instead of this non-relaxing pelvic floor, in some patients the problem is due to insufficient propulsive force being generated in the pelvis (Koutsomanis et al., 1995). An evacuation disorder may occur concurrently with slow gut transit. Slow transit constipation is the result of a failure to move faecal material through the colon at a normal rate. The aetiology of slow transit constipation is unknown, but is likely to be multifactorial.

Patients with neurological problems are at risk of developing both forms of constipation for a variety of reasons. Constipation may be mechanical, with slow gut transit being most common cause (Norton, 2006) (see Box 18.4). Decreased mobility will reduce the movement of faeces through the gut and in patients reliant on others to help them use the toilet this can be further compounded by poor facilities and lack of privacy. Constipation can also be compounded by an inability to take sufficient dietary fibre or fluids and by the side-effects of medication used to treat many neurological problems.

Box 18.4 Neurological causes of constipation

Faecal incontinence

Patients with neurological conditions could present with faecal incontinence (FI) which is involuntary leakage of solid or liquid faecal material, or anal incontinence which is involuntary passing of flatus. The volume of faecal material passed is variable and may involve only a light soiling on underwear, but may be equally distressing to patients and severely impacts on the quality of life. FI is often cited as the reason for admission to nursing home care (Whitehead et al., 2001).

To remain continent patients need to be able to sense when the rectum is filling, to distinguish its contents, to store the faeces for a period of time, and to prevent unwanted leakage of solid, liquid or gas from the anus. Faecal incontinence has many causes and contributing factors among people with neurological conditions (Box 18.5).

Box 18.5 Causes of faecal incontinence (FI) in neurological disorders

ASSESSING BOWEL FUNCTION

A history of co-existing medical conditions, diet and fluid intake, prescribed and over-the-counter medication/laxatives, as well as specific bowel symptoms (Box 18.6) should be taken (Norton and Barrett, 2002). Assessment of stool consistency is aided by using the Bristol Stool Form Scale (Lewis and Heaton, 1997). Bowel symptom diaries may also be completed by patients for seven days and can be particularly helpful in assessing patients who have difficulty recalling symptoms.

Box 18.6 Nursing assessment of bowel symptoms

General bowel symptoms:

Constipation symptoms:

Faecal incontinence symptoms:

Adapted from Norton and Chelvanayagam, 2004.

There are a number of published constipation rating scales, but none have been developed specifically for assessing patients with neurological conditions. If nurses wish to use an assessment tool for FI, this needs to include elements that bother patients the most, including psychological and quality of life issues, such as unpredictability and coping strategies (Cotterill et al., 2008). The faecal incontinence assessment tool of choice, along with user guides, is available from the ICIQ website, together with the assessment tools for urinary incontinence.

BOWEL MANAGEMENT PROGRAMMES

Patients with neurological conditions need to have an individualised, planned bowel management programme rather than dealing with problems as they occur. Any bowel programme should provide predictable and effective elimination of stool using a combination of conservative, pharmacological and/or assistive methods (Wiesel and Bell, 2004). Bowel management needs to take place in a safe, but pleasant environment. While independent bowel care is the ideal, this is not always achievable and consent from the patient must be obtained before carers engage in bowel care, particularly if the patient requires digital removal of faeces. The involvement of the patient’s partner or family is inappropriate in most cases.

Bowel management should ideally be scheduled after a meal to capitalise on the gastro-colic reflex, although there is some evidence that this reflex might be reduced in patients who have suffered spinal cord injury (SCI) and multiple sclerosis (MS) (Wiesel and Bell, 2004). Assistive techniques, such as abdominal massage, seating position and the Valsalva manoeuvre have been used by patients to empty the rectum, but little research has been undertaken. Spinal cord injured patients report finding evacuation easier when sitting than lying in bed (Nelson et al., 1993). Prolonged straining should be avoided as haemorrhoids and rectal prolapse may result. Specific bowel management guidelines have been produced for patients with SCI (SCI Centres of the UK & Ireland, 2009).

Digital ano-rectal stimulation

This technique can be used by patients following spinal injury at T12 or above in whom reflex bowel function is still present. This should be performed by inserting a lubricated, gloved finger into the rectum and slowly rotating against the rectal mucosa (Wiesel and Bell, 2004) (see Box 33.6). This should stimulate peristalsis in the left colon, relaxation of the rectal wall and passage of flatus and stool. Stimulation in this way should be performed for no longer than one minute and repeated every 5–10 minutes until evacuation is complete (Wiesel and Bell, 2004). This technique may be helpful in other neurological conditions, such as stroke, but is unproven as yet.

Management of constipation

Patients with neurological conditions are at risk of developing constipation if a bowel management programme is unsuccessful or for other reasons (see Box 18.3). Most cases of constipation are successfully treated with simple non-pharmacological measures. Medication with constipating side-effects should be reviewed and discontinued if possible.

Diet, fluid and lifestyle changes

Simple measures start with a trial of increased fibre, fluid intake, exercise and lifestyle changes. Adequate fibre intake needs to be maintained as this will normally reduce transit time and increase frequency of defecation. There is little evidence that increasing dietary fibre is effective in the management of severely constipated patients and this may induce symptoms such as abdominal distension and flatulence, particularly in those patients with a slow gut transit. There is some evidence that increasing dietary fibre will increase gut transit time and reduce frequency of defecation in some patients with neurological conditions (e.g. Parkinson’s disease and SCI), but fibre intake is often inadequate and patients should take the amount required to achieve a stool of a consistency that they can easily pass (Coggrave, 2008). There is also no evidence that stool consistency and constipation can be affected by increasing fluid intake or exercise (Müller-Lissner et al., 2005), but if the patient is dehydrated then increasing fluid intake may help. Lifestyle changes around a toileting routine (Box 18.7) to instil good defecatory habits may help.

Box 18.7 Recommended toileting routine

Laxatives

Oral and/or rectal laxatives may be necessary to treat constipation and should be tried according to the patient’s preferences and assessment findings (Wiesel and Bell, 2004). Laxatives should be rotated every couple of months, otherwise they lose their effectiveness. The lowest effective dose of a laxative should be used, and should be reduced as soon as symptoms begin to resolve. Treatment may begin with a bulk-forming laxative (e.g. Fybogel), unless the patient has slow transit. If stools remain hard then the prescription may include or change to an osmotic laxative (e.g. movicol or lactulose). If stools are soft, but difficult to pass, or defecation is incomplete, an oral stimulant laxative may be added (e.g. senna). Rectal stimulants may be required (e.g. glycerine or bisacodyl suppositories) and patients who have poor manual dexterity and wish to maintain their bowel care independently may find a suppository inserter helpful. Should the constipated stool be beyond the reach of the examining finger, then enemas are the next step, but large volume enemas (e.g. phosphate) should be a last resort.

Biofeedback

Gut directed biofeedback training has become an established therapy for constipation and involves patients being taught to defecate effectively by using bracing of the abdominal wall muscles and effective relaxation of the pelvic floor muscles (Emmanuel and Kamm, 2001). Balloon systems or electrical stimulation can be used as forms of biofeedback, but both rely on the patient learning to recognise appropriate relaxation of the pelvic floor. One study has shown the effectiveness of this intervention for some people with bowel problems as a result of MS (Wiesel et al., 2000).

Transanal irrigation (Peristeen)

Transanal irrigation has been used to treat both intractable constipation and faecal incontinence (Christensen et al., 2006). The patient sits on the toilet and instils between 750 ml to a litre of water via a specially lubricated short rectal catheter with an integral balloon to keep it in place. Although the initial research was undertaken in a group of patients with SCI, it is now being more widely used by specialist nurses with patients with other neurological conditions, e.g. MS. The Peristeen Anal Irrigation System (Coloplast Ltd) has been licensed for transanal irrigation in the UK.

Digital removal of faeces (DRF)

DRF, also known as manual evacuation, should only be used when required, with patient consent and by a skilled individual. The technique involves inserting a lubricated, gloved finger to break up and hook the stool out (see Box 33.6). This noxious stimulation may trigger autonomic dysreflexia (see Chapter 33) in patients following SCI and anaesthetic lubricant can help to reduce this. Patients with an areflexic bowel following SCI at L1 or below rely on DRF to evacuate their bowel and there is no alternative. Nurses must ensure that they are competent to undertake this procedure (RCN, 2008; NPSA, 2004).

Management of faecal incontinence

There is little evidence underpinning prevention and management of FI and guidance has developed from expert consensus (NICE, 2007). Treatment options for FI remain limited and under-researched. A treatment programme combining a regular planned bowel management routine using dietary manipulation, pharmacological treatments to control stool consistency and behavioural techniques is often helpful. The aim of management is often to reduce the volume of stool produced, alter the consistency to a more solid, formed stool and then use suppositories/enemas to evacuate the bowel. This enables the patient to deal with their bowel management at a time and place that suits them and reduces the fear of unpredictable leakage or accidents.

Pharmacological interventions

Several drugs are used in the pharmacological management of FI to either induce constipation, bulk the stools or aid defecation (Box 18.8). These drugs are often used as an adjunct to other behavioural or surgical interventions. Constipating agents are used to reduce the volume of the stool produced and firm up the consistency of liquid stools, although they are not licenced for treatment of FI. Loperamide may be useful for liquid stools once the cause has been established. It is taken regularly before meals and can be an effective treatment for faecal incontinence, but side-effects include constipation (Cheetham et al., 2002).

Box 18.8 Commonly used drugs used to manage faecal incontinence

Constipating agents:

Bulking agents:

Some patients, particularly those with spinal and other neurological problems, may require bowel evacuation using suppositories, enemas or digital removal of faeces if constipating agents are used, and care must be taken to ensure that the patient does not become impacted. Use of a constipating agent in combination with an evacuation aid makes bowel evacuation more predictable and enables it to be planned at a time to suit both the patient and carers. This may be a particularly important factor to consider when planning a bowel management programme for patients requiring nursing assistance in the community.

Biofeedback for FI

Stimulation to the rectum, either using air (in a balloon) or an electric current, assists the patient in identifying and improving tone and contraction in the external anal sphincter. Evidence to support the use of biofeedback compared to conservative management remains limited (Norton et al., 2006), but there is some evidence that patients with mild to moderate MS might find it helpful for FI (Wiesel et al., 2000). A recent Cochrane review of the role of biofeedback and/or sphincter exercises did not provide conclusive evidence of the effectiveness of the therapy, although there was some evidence that elements of biofeedback may have had some therapeutic effect (Norton et al., 2006).

Electrical stimulation

Electrical stimulation has been used to treat urinary incontinence for many years and more recently has been increasingly used for faecal incontinence, although once again there is extremely limited evidence of effectiveness (Hosker et al., 2007). Electrical stimulation aims to enhance voluntary anal sphincter contraction or sensation. It is unclear how frequently this needs to be applied and for how long a period of time or where the electrodes are best placed, in order to be effective.

Anal plugs

Anal plugs can also be an effective form of management for some, but tend to be better tolerated by patients with poor ano-rectal sensation. Other patients find the plug uncomfortable to wear (Norton and Kamm, 2001), but they do allow patients a certain amount of freedom to go about activities of daily living without fear of an episode of FI. Many patients will use plugs on ‘special occasions’, when they need to be sure that they will not have a bowel accident while out.

Anal plugs are inserted into the rectum and sit above the sphincters. These plugs come wrapped in a water soluble film, so vaseline must be used for insertion, rather than a water-based lubricant. If water soluble lubricants are used, the covering of the plug will begin to dissolve, causing the plug to open prematurely and making insertion difficult. On contact with the natural moisture in the rectum the plug expands to form a barrier to faecal leakage. It can stay in position for up to 12 hours and is permeable to flatus. Removal is achieved by pulling gently on a gauze ‘tail’ which hangs from the anus.

SUMMARY

Bladder and bowel problems are common and have a significant impact on quality of life for people with neurological conditions. It is imperative that an interdisciplinary approach is taken to assessment and management, but nursing staff are ideally placed to coordinate care and initiate simple interventions. This can also be done in conjunction with specialist nurses in continence care.

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