anal incontinence

Patient care

Health care professionals should make questions about incontinence a routine part of taking a patient's history because the patient may be too embarrassed to report the problem without prompting. The type of episodes experienced should be documented and how long the problem has been present. Many factors may be involved, including neurologic disorders, urinary tract infection, adverse drug effects, irritants such as artificial sweeteners, caffeine, certain foods, and decreased muscle tone. Physical examination should follow up on the problem, and a urologic consultation may be warranted.

Functional UI may afflict older adults who have normal bladder control but have a difficult time getting to the toilet because of problems that interfere with mobility, e.g., arthritis, Parkinson disease, or stroke. Environmental factors (such as clutter, lack of ready access to facilities, distance to the toilet) may also play a part. Health care professionals should assess the patient’s fluid intake to be sure he or she is drinking enough and should review his or her medication regimen to determine if any of the drugs affect continence. The patient should be encouraged to use the toilet on a planned schedule (upon arising, before and after each meal and at bedtime, and as adjusted to his or her needs). For patients living independently, walkways should be kept free of clutter, and, if necessary, a commode placed closer to the person’s living space.

Patient care

Overflow incontinence is more common in men than in women and requires further evaluation because it may be triggered by diabetes mellitus, multiple sclerosis, spinal injury, or benign prostatic hypertrophy. Sterile intermittent catheterization or an indwelling urinary catheter may be prescribed because retained urine can lead to infection and other complications. Male patients may benefit from alpha-adrenergic antagonists such as prazosin and terazosin, which decrease bladder outlet resistance and improve emptying. Patient, family, home health aides, and long-term-care health care assistants involved with the patient’s care should be taught about adverse reactions to these drugs, which need to be observed for and reported and include postural hypotension, palpitations, headache, nausea, and dizziness. If the patient feels dizzy while taking medications for incontinence, he or she should be advised to sit or lie down and taught to change position slowly. The patient should not drive or operate machinery of any kind until he or she knows how the drug affects his or her safety and mental alertness.

Coping strategies for overflow incontinence include allowing enough time for toileting and providing external collection devices such as a urinal or external (condom) catheter at night. Teaching the patient to perform a Credé method (applying gentle pressure above the symphysis pubis in a downward direction with the blade of the hand) may increase emptying. Assessing residual urine with a portable noninvasive bladder ultrasound scanner, and following with intermittent catheterization if the residual amount is above specified limits, can assist the patient in learning to empty the bladder.

Diagnosis

Direct observation of urine loss while coughing is a reliable method of establishing this diagnosis. Laughing, sneezing, lifting a heavy object, and exercising are other triggers. The urine should be cultured to rule out urinary tract infection. Ultrasound of the bladder after the patient voids establishes the residual urine volume and helps rule out retention with overflow. Stress urinary incontinence should be investigated to ensure that it is not caused by a structural abnormality.

Treatment

In addition to using devices to absorb urine that escapes, therapy consists of behavioral modification, pharmacological treatment, and surgical management. Behavioral therapy includes bladder training, timed voiding, prompted voiding, and pelvic muscle (Kegel) exercises. Pharmacotherapy includes oxybutynin hydrochloride, propantheline bromide, and imipramine hydrochloride. Surgery may restore anatomic support of the urethra or compensate for a poorly functioning urethral sphincter. The American Urological Association considers sling procedures and retropubic suspensions the most effective surgeries long term. The transvaginal tape (TVT) sling procedure is performed as outpatient surgery under local anesthesia with a small vaginal incision and two small suprapubic incisions. The sling supports the urethra during stress and the increases in intra-abdominal pressure that occur during routine activities. See: bladder drill; Kegel exercise

Patient care

The patient is taught Kegel exercises to strengthen pubococcygeal muscles and encouraged to practice the exercises at frequent intervals throughout the day, as well as during urination (by stopping and starting the urinary stream intermittently). The vulva and introitus should be kept clean and dry and free from free. Commercial barrier products should be used to protect clothing. To avoid the social isolation and depression that may result from this condition, the patient should be encouraged to continue or resume usual activities while using protective barriers. The patient's response to the exercise regimen is periodically evaluated. If conservative therapies are ineffective, surgery may be recommended to improve not only the urinary problem but also the patient’s quality of life. Postoperative precautions include: avoid lifting objects weighing 15 lb (6.8 kg) or more for 3 months; avoid driving for 1 to 2 weeks; avoid strenuous exercise (running, cycling) for 4 to 6 weeks; avoid tub baths for 4 weeks (may shower immediately); refrain from sexual intercourse for 4 weeks. Oral analgesics are prescribed for discomfort expected during the first 24 to 48 hr. Continued or increasing pain, blood in the urine, or painful or difficult urination should be reported.

Patient care

Healthy older adults may develop urge incontinence, but it also can affect those who have suffered a stroke or who have Alzheimer disease, Parkinson disease, multiple sclerosis, or diabetes mellitus. Bladder retraining and Kegel exercises should be the first therapies for urge incontinence. The patient should maintain a regular toileting schedule, beginning with every 1 to 2 hr, then gradually increasing the time between voiding. Keeping a diary of fluid intake, urine output, and any episodes of incontinence helps the patient and the primary health care provider recognize patterns and revise the regimen as needed. The patient should carry out Kegel exercises when the urge to void starts because these exercises help strengthen perineal muscles, which may provide the patient more time to reach the toilet. Anticholinergic drugs, such as oxybutynin and tolterodine, that inhibit the detrusor muscle of the bladder can be prescribed. Patients should be aware of potential adverse effects, which include confusion, dry mouth, dry eyes, urinary retention, constipation, and blurred vision.

Treatment

Therapy will depend upon the cause. Information on this subject may be obtained from Health for Incontinent People at 800-251-3337.