Continence is how the bladder and bowel work, however there are a number of influences that can affect this. These can impact on continence and cause incontinence or leakage of either the bladder and/or bowel. It is a ‘taboo’ subject and for this reason individuals are often reluctant to seek help (Bedoya-Ronga and Currie, 2014). Indeed, continence is not discussed openly as a condition, so it is crucial that both sufferers of this condition, carers and healthcare professionals understand the impact that continence issues can have on everyday lives.
This article, the first in a clinical skills series, identifies continence problems that affect individuals. It looks at definitions of bladder and bowel continence problems, outlines the prevalence of the condition, and discusses the different types of incontinence from which individuals can suffer. It also identifies associated complications that can occur and the effects these can have on patient quality of life.
DEFINITIONS 
It is important that healthcare professionals understand what ‘incontinence’ means and how there are different definitions for each type of problem. Here, only the most common types of bladder and bowel problems are defined. 
Bladder 
Urinary incontinence (UI) has a broad generic definition identified by the International Continence Society (ICS) as ‘any involuntary leakage of urine’ (Abrams et al, 2002; Haylen et al, 2010). 
 
This is then subdivided into specific types of UI, namely: 
  • Stress urinary incontinence (SUI) — defined by the ICS as ‘the complaint of any involuntary loss of urine on effort or physical exertion (e.g. sporting activities), or on sneezing or coughing’ (Haylen et al, 2010)
  • Urge incontinence (overactive bladder) — when urine leaks as you feel a sudden, intense urge to pass urine, or soon afterwards (NHS Urinary Incontinence, 2019) 
  • Overflow incontinence (chronic urinary retention or obstructive incontinence) — when the patient is unable to fully empty their bladder, causing frequent leakage (NHS Urinary Incontinence, 2019)
  • Functional incontinence — sometimes known as disability-associated urinary incontinence. It occurs when the person’s bladder and/or bowel is working normally but they are unable to access the toilet. This may be due to a physical or cognitive condition, i.e. arthritis or dementia (Continence Foundation of Australia, 2020).
Bowel 
Unlike the bladder, bowel problems do not have an overarching generic definition, but rather a multitude of definitions according to presentation of symptoms. The Royal College of Nursing (RCN, 2019) has identified:
  • Faecal incontinence (FI) — involuntary loss of liquid or solid stool that is a social or hygienic problem
  • Anal incontinence (AI) — involuntary loss of flatus, liquid or solid stool which is a social or hygienic problem (Bliss et al, 2017) 
  • Passive soiling (liquid or solid) — this occurs when an individual is unaware of liquid or solid stool leaking from the anus; this may be after a bowel movement, or at any time.
However, leakage is not the only (or most common) problem associated with the bowels. Constipation is far more prevalent and the Rome IV criteria (Drossman et al, 2017) categorises disorders of chronic constipation into four subtypes:
  • Functional constipation 
  • Irritable bowel syndrome with constipation 
  • Opioid-induced constipation 
  • Functional defaecation disorders, including obstructive defaecation or anismus (inappropriate tightening of, or inability to relax the muscles in the back passage and pelvic floor, making it difficult to open bowels and pass stools) (Aziz et al, 2020).
PREVALENCE 
The prevalence of incontinence is variable and potentially unknown. This is mainly due to the embarrassing nature of the condition and reluctance of sufferers to discuss or come forward with the problem (Bedoya-Ronga and Currie, 2014). It could also be caused by the multitude of different definitions given for the different types of problems and what definition is used when data/ information is collected with regards to bladder/bowel problems. However, what is known is that it is a common problem and, while often associated with ageing, it is not an inevitable part of the ageing process (Day et al, 2014; Yates, 2019).

Prevalence factors are sometimes identified in, but are not exclusive to, specific groups of individuals, e.g. those living in long-term care facilities, women who are pregnant and postpartum, the elderly, obese individuals, post-surgical interventions (hysterectomy, radical prostectomy), and those with cognitive and physical impairment (Bliss et al, 2017).
Urinary incontinence 
Within the UK, an estimated 14 million individuals are affected by UI (NHS England, 2018), with 61% of the general population of men experiencing lower urinary tract symptoms (LUTS) and 34% of women living with UI (NHS England, 2018). Stress urinary incontinence accounts for approximately half of all UI (Milson et al, 2017), with most studies reporting 10–39% prevalence (Hannestad et al, 2000; Abrams and Artibani, 2004).

Mixed incontinence (a combination of stress and urge incontinence) is found to be the next most common, with most studies reporting 7.5–25% prevalence (Milson et al, 2017). Urgency incontinence on its own has a prevalence of 1–7%, and other causes of incontinence approximately 0.5–1% prevalence (Milson et al, 2017). Approximately 10% of all adult women report leakage at least weekly. Occasional leakage is much more common, affecting 25–45% of all adult women. Hunskaar et al (2005) estimated that 4–7% of women under and 4–17% over the age of 60 have daily episodes of UI. These figures increase with age, with one-fifth of over 85 year olds suffering with ‘severe or profound’ UI (Collerton et al, 2009). 

Prevalence studies on UI in community-dwelling men shows prevalence rates from 4.81–32.17%, with prevalence increasing with age (Milson et al, 2017). The prevalence of UI in men has not been investigated to the same extent as for females, and it appears that UI is at least twice as prevalent in women compared with men (Milson et al, 2017). 
While SUI is more prevalent in women, the increasing prevalence of any UI by age in men is largely due to the contribution of urgency UI rather than SUI (Milson et al, 2017). Post-surgical UI after radical prostatectomy is frequent, ranging from 7–57% (Daugherty et al, 2017; Hislop et al, 2020).

Bowel incontinence 
Over 6.5 million adults suffer with bowel control problems, with one in 10 affected by faecal incontinence (Yates, 2017; NHS England, 2018). Approximately half a million adults suffer with faecal incontinence that has a negative impact on their quality of life (National Institute for Health and Care Excellence [NICE], 2015; NHS England, 2018). The prevalence of anal incontinence increases with age but is present in all age groups in both genders, varying from 1.5% in children to more than 50% in nursing home residents (Milson et al, 2017). It is almost as common in men as in women. Nearly two-thirds of people with faecal incontinence also have urinary incontinence — ‘double incontinence’ (NICE, 2014). As said, faecal incontinence is closely associated with age and is prevalent in residential/nursing homes, with one in three suffering in residential homes and two in three in nursing homes (NICE, 2014; NHS England, 2018). In later life, the majority of bowel problems are related to constipation (Heath, 2009; Yates, 2017). 
TYPES OF INCONTINENCE 
Continence problems present in many different ways, with varying symptoms and causes. With regards to the bladder, the most common issues are stress, urge, mixed, overflow and functional urinary incontinence (Table 1). 
Stress urinary incontinence 
This is associated with a weak pelvic floor and is the most common type of incontinence found in women (due to childbirth), although men can suffer with this type after prostate surgery (Milson et al, 2017). It is associated with leakage after coughing, sneezing, laughing, exertion/exercise and is usually a small amount of leakage (Yates, 2016). 
Urge urinary incontinence 
This is caused by unstable bladder contractions when the detrusor muscle (the smooth muscle found in the bladder wall) contracts on filling and is defined as the complaint of ‘involuntary leakage accompanied by, or immediately preceded by urgency’ (Abrams et al, 2002; Meng et al, 2012). Leakage can vary from a small/moderate amount to a full bladder. Symptoms can include frequency of micturition (over eight times in 24 hours), urgency, nocturia, and leakage. 

Mixed incontinence 
This is where both stress and urge symptoms occur together. Defined as ‘the complaint of involuntary leakage, associated with urgency and also with exertion, effort, sneezing or coughing’ (Abrams et al, 2002; Haylen, 2010). 

Overflow incontinence 
This type of incontinence happens when the bladder does not empty completely. It is usually associated with: prostate enlargement (benign prostatic hyperplasia [BPH]) in men; prolapse in women; urethral strictures; underlying neuropathic conditions, i.e. spina bifida, Parkinson’s or multiple sclerosis, diabetes, cerebrovascular accident (CVA), spinal cord or brain injury; or can be due to chronic constipation (Yates, 2016). 

Functional incontinence 
Factors that can affect functional incontinence include: 
  • Cognitive function, i.e. dementia, CVA, Parkinson’s, etc 
  • Physical function, such as mobility to get to the toilet in time, poor dexterity to adjust clothing in time, or anything that affects ability to be independent, e.g. failing eyesight, overgrown toenails, breathlessness (Yates, 2017). 
 
 
Bowel problems can present with either storage issues, causing faecal incontinence or faecal urgency, or expulsion issues, resulting in constipation or faecal impaction (Table 2). In the majority of cases, these symptoms can be improved or cured by identifying and treating the underlying causes, based on a correct initial assessment (NHS England, 2018; Yates, 2018). 
 
To maintain bowel continence, individuals will be dependent on several major factors: 
  • An effective barrier to outflow provided by an acute anorectal angle and anal sphincters 
  • Intact internal anal sphincter to ensure no passive leakage of stool 
  • Intact external anal sphincter to be able to defer defaecation and reduce bowel urgency 
  • Intact rectal and anal sensation 
  • Compliant, distensible and evacuable reservoir (rectum) 
  • Intact central nervous system 
  • Bulky and formed faeces (Norton and Chelvanayagam, 2004; Yates, 2017). 
For some people, there will be a single cause why these systems do not work with regards to faecal incontinence, while for others, it will be multifactorial. Risk factors are identified in Table 2. 
COMPLICATIONS AND QUALITY OF LIFE 
Although continence problems are not regarded as life-threatening, they can significantly affect quality of life of patients and their families. NHS England (2018) states that ‘incontinence produces marked loss of self-esteem, depression, loss of independence, and can affect relationships and employment prospects’. It also says, ‘it is an important component in a person’s health and wellbeing at any stage of life’. 

Other complications associated with incontinence, which can occur and increase loss of independence, are bacterial infections, fungal infections, as well as cellulitis (Beeckman et al, 2015; Yates, 2020). Psychological effects which can impact on patient quality of life can be sexual dysfunction, loss of respect and self-confidence, shame, avoidance of social events, reduced personal activities and maintenance of relationships, social insularity and isolation, loss of independence, occupational aspects and increasing financial costs to cover management, i.e. extra washing, purchasing equipment (NHS England, 2018). 

While psychological complications associated with continence issues are highlighted, physical harm relating to continence problems is also common. The most common complications can include skin damage, falls or fractures, and urinary tract infections (UTIs) (NICE, 2015; Soliman et al, 2016; Yates, 2018). 
Skin damage 
Poor continence care is a contributory factor for incontinence-associated dermatitis (IAD) (or moisture-associated skin damage [MASD]) and pressure ulcers. IAD has been described as a type of ‘irritant contact dermatitis’ (Beeckman et al, 2015). It may be associated with infection and can occur on intact or damaged skin (Iblasi et al, 2019). IAD occurs in people who are incontinent of urine and/or faeces (Beeckman et al, 2015) and is one of the most common skin problems in this group (Iblasi et al, 2019). Contributory causes for IAD include: 
  • Incontinence 
  • Prolonged exposure of skin to urine and/or faeces — this may not necessarily be due to incontinence but for those who need assistance to maintain hygiene, which may not be available when needed 
  • Poor assessment of incontinence 
  • Inappropriate use of continence aids/pads 
  • Inappropriate cleansing regimens (Gray and Giuliano, 2018; Yates, 2020).
It can be improved by addressing these issues. 
Falls 
Falls have a significant impact on individuals, their families and the health service. Considerable effort has gone into identifying predisposing factors for falls, injurious falls and fractures, and patients with incontinence are 26% more likely to fall and 34% more likely to fracture (Soliman et al, 2016). Indeed, it has been identified that falls are one of the leading causes of injury-related visits to accident and emergency departments and one of the causes of accidental deaths in over 65s (Soliman et al, 2016). 

Falls are an indicator of declining health and deteriorating motor function, and the mortality rate associated with falls dramatically increases in the over 75s (Soliman et al, 2016). People do not just fall due to age; there are often contributory risk factors and incontinence has been shown to be one, alongside medical conditions, i.e. prostate problems, arthritis, safety hazards (slippery floors, poor lighting, loose rugs, poorly fitting footwear), and medication (Soliman et al, 2016; Yates, 2017).
Prevention of falls could be partly accomplished by assessing continence needs required on a holistic basis with a multidisciplinary team involved. It has also been identified that an overactive bladder is an important risk factor for falls due to rushing to the toilet (Yates, 2017; NHS England, 2018). 
Urinary tract infections (UTIs) 
Urinary tract infections (UTIs) can either cause continence problems on a transient basis or can be a contributory factor to long-term continence issues. UTIs are more common in women, with 10–20% experiencing a symptomatic UTI at some point in their lifetime. UTIs increase in prevalence with age in both sexes, with an estimated 10% of men and 20% of women aged over 65 years having symptomatic bacteriuria (NICE, 2015). 

Urinary infections are known to cause frequency of voiding, pain, urgency and, in the elderly, can cause confusion, agitation, behavioural changes and can be associated with falls (Yates, 2015). They can also be associated with sepsis if not identified and interventions put in place (Department of Health [DH], 2016; NHS England, 2018). This can be assisted by undertaking a good continence assessment. 
CONCLUSION 
Although not a life-threatening condition, continence does have a major impact on an individual’s quality of life and the lives of their family and carers. Prevalence is high and the condition can affect anyone regardless of age, gender or ethnicity. However, continence issues do have an affinity for certain groups of individuals. Different types of continence problems vary, so it is important that healthcare professionals can distinguish between them. Complications that arise from incontinence are also variable and can have drastic effects, which can be costly both to the individual and health service. These can be addressed by better assessment and initial investigations, which the next article in this series will look at.
KEY POINTS 
  • Although continence problems are not regarded as life-threatening, they can significantly affect quality of life of patients and their families. 
  • Continence is a common problem and, while often associated with ageing, it is not an inevitable part of the ageing process. 
  • With regards to the bladder, the most common issues are stress, urge, mixed, overflow and functional urinary incontinence.
This piece was first published in the Journal of Community Nursing. To cite this article use: Yates A (2021) Clinical skills. Part 1: Continence issues: an overview. J Community Nurs 35(1): 22-28

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