Continence problems

What is continence?

Continence, or the ability to control when you urinate or empty your bowels, is a vital component of a person’s health and wellbeing. Unfortunately, problems with continence are common following a brain injury, particularly in the first several weeks. For many people, this loss of toilet control is a very sensitive issue, and people can feel as though they are losing their dignity.

Urinary and bowel continence problems can occur alone or at the same time, and can range in severity from just a small leak to a complete loss of function. Some people may experience continence problems on a daily basis, whereas for others it may only happen from time to time. This can be physically and emotionally difficult for not only the brain injury survivor, but also those around them, and can have a major impact on daily life. Fortunately, with time and practice, many people regain control of their bladder and bowel functions. However, for others, continence problems can be an issue that they will need to manage in the long-term.

Types of continence problems

There are different types of continence problems that can occur, sometimes in combination, as a result of brain injury:

• Neurogenic - damage caused by a brain injury preventing messages from being transmitted between the brain, bladder and bowel

• Functional - physical disabilities or problems with cognition and communication preventing a person from getting to the toilet on time

• Frequency - the need to pass urine or faeces more often than normal

• Urgency - a sudden and uncontrollable need to pass urine or faeces at unexpected times

• Nocturnal enuresis - the need to go to the toilet several times during the night or wetting the bed while asleep

• Stress - leaking urine or faeces during physical movement or activity, such as coughing, sneezing, laughing, lifting or passing wind

• Reflex - no sensation that the bladder or bowel are full, therefore passing urine or faeces without realising it

• Retention - straining or difficulty emptying the bladder or bowels (i.e. constipation)

• Overflow - the bladder or bowels over-fill and leak due to loss of feeling

If someone is constipated, this can also press on the bladder, worsening any bladder problems that may be present. This is called faecal impaction.

Continence problems and brain injury

There are a number of reasons why someone may have problems with their bladder and bowel function following brain injury. These may include:

• Damage to the part of the brain that controls bladder and bowel functions

• Being unconscious and unaware of the surrounding environment

• Peripheral nerve damage preventing messages from being transmitted between the brain, bladder and bowel

• Being less mobile than usual

• Eating and drinking less than usual

• Physical difficulties affecting one’s ability to remove clothing and/or reach a toilet in time

• Weakness in the muscles controlling the outflow of urine or faeces

• Communication difficulties affecting one’s ability to indicate the need for the toilet

• Memory problems affecting one’s ability to recall when they last went to the toilet or remember the location of toilet facilities

• As a side effect of commonly prescribed medication (e.g. diuretics)

For the majority of people, these problems will resolve over time. However, if problems do persist in the longer term, there is help available.

Initial care after brain injury

If someone is in hospital following a brain injury, there are a number of ways in which continence problems can be managed by the medical staff until the patient is ready to start actively regaining control of their bladder and bowel function. The staff may use the following:

• High-absorbency pads and pants

• Catheters - a fine tube inserted into the bladder to drain urine

• Other urine collection devices such as handheld urinals or sheaths (a condom-like catheter for men)

• Faecal collection devices (most often used in intensive care)

• Anal plugs

Those who do have good bladder and bowel functions, but are unable to indicate the need for the toilet, will be offered the toilet or commode (a chair with a removable potty under the seat) throughout the day. If the patient is bed bound, they may be transferred using a hoist, or given a portable urinal or bed pan to use.

When appropriate, the medical team will undertake a full assessment to establish the underlying cause of the patient’s continence problems. The physical, cognitive and emotional function of the patient will also be taken into account.

Continence assessment

The continence assessment may include:

• Completing a questionnaire, and a bladder and bowel chart prior to the appointment

• Providing the patient’s medical history

• Reviewing any medication that is being taken

• Gathering information about the patient’s fluid and diet intake

• A urine sample analysis to check for possible infection

• A physical examination

• A bladder ultrasound scan

• An abdominal x-ray

• Any other specialist investigations

Once the cause of the patient’s continence problems has been determined, an individualised treatment programme will be devised. The medical staff will teach the patient and their loved ones how to manage the continence problems, as well as arrange for a supply of any necessary products before discharge. The patient may also be seen by a specialist continence nurse advisor or consultant (such as a urologist), or be referred to other services and professionals for further support.

If someone is at home following a brain injury and experiencing continence problems, it is important that they visit their GP.

What treatments are available?

Treatment options for bladder and bowel continence problems depend on the underlying cause, as well as the degree of severity. In some cases, more than one treatment may be needed. Common options include:

• Bladder training involves learning new techniques to hold urine for longer periods of time. It is achieved by making regular visits to the toilet, then gradually extending the time between each visit.

• Bowel training involves establishing regular times to make a bowel movement, often after mealtimes, and learning to delay these movements once on the toilet.

• Pelvic floor exercises can strengthen the muscles that are used to stop leakage of urine from the bladder.

• Electrical stimulation devices can also strengthen the pelvic floor muscles by contracting them frequently using electric currents.

• Enema and/or rectal irrigation involves instilling warm water into the rectum via the anus, stimulating the bowel to contract and flush out its contents.

• Medication can be prescribed to reduce bladder and bowel movements.

• Surgery may be performed if symptoms are severe and other treatments are ineffective.

• Lifestyle changes, for example:

  • Keeping fit (if someone is able)

  • Cutting down on caffeinated drinks and drinking enough water

  • Following a balanced diet, for example, eating plenty of fruits and vegetables containing fibre

  • Losing weight (if someone is overweight)

  • Quitting smoking (a smoker's cough can weaken the bladder and bowel muscles)

Living with ongoing continence problems

For some brain injury survivors, continence problems may be an issue that they will need to learn to manage in the long-term. If this is the case, you are not alone. With the right advice and preparation, continence problems can be managed.

Specialist products available to help manage ongoing continence problems include:

• High-absorbency pads and pants

• Washable or disposable seat pads to protect furniture

• Washable or disposable mattress protectors and bed pads

• Commodes (particularly useful to have in the bedroom at night)

• Alarms to sound at regular intervals throughout the day and night

• Catheters or other urine collection devices for men and women

Which professionals can help with managing continence problems?

Other professionals who can often help with managing continence problems include:

• Continence advisors are clinical nurses with specialist training in continence care. They are able to assess a patient’s bladder and bowel problems, and advise on treatment and management. Continence advisors may visit the person being cared for at home or at a local continence clinic. The Bladder and Bowel Community can provide details of your local continence clinic using their ‘Healthcare Search Tool’. Your GP will also be able to advise on this.

• A physiotherapist can provide tips and exercises to improve mobility, which may help the patient access the toilet more easily. They can also assist if pelvic floor exercises have been recommended.

• An occupational therapist can assist if the patient needs to make adaptations to their home. For example, the patient may need handrails or a raised toilet seat fitted, or they may need walking aids or a wheelchair.

• A dietitian can recommend suitable food and fluids to help the patient with their bladder and bowel problems.

• A speech and language therapist can assist with any communication issues that might be present, for example, if the patient struggles to indicate the need for the toilet. In addition, they can assess any swallowing difficulties that are causing the patient to eat and drink less than usual.

Caring for someone with continence problems

Continence problems can be one of the most difficult aspects of caring for someone with a brain injury. It is often unpredictable and can be physically and emotionally demanding. Toileting is also a very personal issue and often those who experience continence problems feel as though they are losing control. Many brain injury survivors will find it difficult to accept that they need help, especially if the help is coming from someone close to them.

Tips for carers:

• Watch discreetly for signs that the person needs the toilet, such as fidgeting, pacing, getting up and down, or pulling at their clothing. This is especially important if the person cannot communicate the need to go clearly.

• Make sure to give regular reminders about using the toilet.

• Check the person has finished on the toilet and not become distracted or forgotten.