It has been identified (McClurg et al, 2013) that assessment of continence problems should be undertaken by an experienced professional, in line with recommended minimum standards (United Kingdom Continence Society [UKCS], 2015).
While the assessment process may be carried out in various ways, especially during the current pandemic (Laws, 2020), there are benefits to an initial face-to-face consultation. Using face-to-face contact, healthcare professionals can use observational skills that may highlight an individual’s (and family/carers’) behaviour, feelings and attitudes, and current coping mechanisms towards the problem (McClurg et al, 2013; Yates, 2019a). This gives the assessor valuable information for symptom control, treatment options and/or management.
A basic continence assessment should comprise (Yates, 2019a):
  • Type of continence problem, i.e. main complaint
  • Information about the onset, duration and current presentation of the symptoms and whether related to a specific event/condition, as well as effect on current quality of life and current management
  • Complete medical, surgical, obstetric, neurological and mental health history, details of any allergies, mobility, dexterity, and cognitive issues, body mass index (BMI) or social issues. These can cover environmental factors that may affect continence, e.g. access to toilets, i.e. due to stairs, access to carers at appropriate times, sharing rooms/facilities, chair/bed heights, toilet height, space to accommodate equipment (e.g. walking aids/wheelchairs), floor surfaces, and unclear signage (adapted from Staskin et al, 2013; National Institute for Health and Care Excellence [NICE], 2010; 2014; 2015; Yates, 2018)
  • Details of all medication, including over-the-counter medication, herbal remedies and recreational drug use.
These findings can be supported by some basic investigations, including (Yates, 2019a; Colley, 2020):
  • A completed bladder and/or bowel chart/diary (usually three days for bladder and one week for bowel problems), or some form of observational chart completed by carers/healthcare professionals if an individual is unable to complete their own chart
  • Details of fluid intake (including amount and type of fluids) and dietary intake to establish a baseline or any triggers relating to problem
  • Dipstick urinalysis — used at an initial continence assessment only as a screening rather than diagnostic test. This assists to rule out dehydration and other medical issues, including renal problems, diabetes and potential urinary tract infections (UTIs)
  • Bladder scans — if presenting with symptoms of poor flow, feelings of incomplete emptying and recurrent UTIs, or there is an underlying neuropathy
  • Examinations (vaginal/rectal/abdominal/neurological), if required, but should only be performed by a competent healthcare professional.
These elements of the basic assessment will now be discussed in more detail.
 

INITIAL PROBLEM AND PRESENTING SYMPTOMS

At initial assessment the type of continence suffered should be identified, i.e. bladder, bowel and/or both, as well as the duration of the problem — has it been something suffered for many years and the individual has only just sought help or is it an acute recent problem. The issue may also be identified as having an association with a particular event, e.g. childbirth, illness or surgery. It is also important to ascertain if the patient has noted any triggers that make the problem worse. Asking specific questions relating to continence status and listening with empathy is vital to identify type of incontinence and subsequent treatments. Questions may include:
  • Do you ever leak urine or faeces on coughing, sneezing or exertion?
  • Do you have any leakage for no obvious reason, leak all the time, is leakage unpredictable, leak during sexual intercourse, when you think you have finished?
  • Do you ever have any urgency to rush to the toilet for either your bladder or bowel with or without leakage?
  • Does your bladder or bowel ever wake you up at night to use the toilet, and, if so, how often?
  • If you have any accidental leakage of urine or faeces, how often does this occur and how much leakage?
  • Do you ever have any frequency to pass urine or faeces?
  • Do you ever have difficulty initiating going to the toilet to pass urine/faeces?
  • Do you ever experience any of these bladder symptoms: hesitancy, straining, poor/ prolonged flow, dribbling of urine, feelings of incomplete emptying, burning or pain?
  • Do you ever experience any of these bowel symptoms: pain, bleeding, straining to pass stool, feelings of incomplete emptying, passing of involuntary flatus (wind)?
  • How do you manage current symptoms?
Symptoms should be recorded as they present. There are many assessment tools and validated symptom profiles/quality of life tools available. The International Consultation Incontinence Questionnaire (ICIQ), which also comes in a shortened version (ICIQ – short form), covers both female and male urinary issues. For men, the International Prostate Symptom Score (I-PSS) poses seven questions, of which six relate to urinary continence symptoms and one relates to quality of life. For bowels, there is the St Mark’s incontinence score or the ICIQ-B bowel questionnaire. Most of these tools are accessible and free (UK Continence Care Society, 2015; NHS England, 2018).
 

HEALTH STATUS

The influence of continence status on an individual’s underlying medical condition cannot be underestimated. It is imperative that any healthcare professional undertaking an initial continence assessment understands how health conditions affect continence (NICE, 2015; Yates, 2018). Diabetes, stroke, spinal cord injury, multiple sclerosis, dementia or any other type of neuropathy have significant impact on continence status. Surgery, such as hysterectomy, prostatectomy, haemorrhoidectomy, or surgery that limits mobility, e.g. hip replacement, spinal surgery can all have an effect on continence.
Other conditions that can also affect continence status are learning disabilities, depression or gastrointestinal problems. However, obstetric history has one of the most dramatic effects on both urinary and faecal continence status and has been associated with pelvic floor and anal sphincter damage (Abrams et al, 2017; Yates, 2019b). This can be especially after the birth of a first baby and any instrumental deliveries, e.g. forceps. The assessor needs to know how many pregnancies, weight of baby (especially over 4kgs), type of delivery, any midline episiotomy and any abnormal presentation.

PRACTICE POINT
 
This year the Royal College of Nursing (RCN) has published a guidance document Bladder and bowel care in childbirth. The aim of the guidance is to provide information about bladder and bowel care throughout pregnancy, labour and into the postnatal period. 
 
Royal College of Nursing (2021) Bladder and bowel care in childbirth. Available online: https://www.rcn.org.uk/professional-development/publications/rcn-bladder-and-bowel-care-in-childbirth-uk-pub-009-553

 
Kolodynska et al (2019) also identified that it is important to know a woman’s menopausal status, as the prevalence of incontinence increases with the effects of lack of oestrogen due to ageing (30–40% in middle age and up to 50% of women in old age compared to only 20–30% in young women). Any allergies should also be noted as well as BMI and smoking status. In 2014, a study was conducted to evaluate the relationship between BMI and incontinence in adults from the UK, United States and Sweden. Results were consistent in showing that BMI is strongly associated with a greater risk of urinary incontinence (Subak et al, 2009; What is the link between obesity and incontinence, 2018). Finally, environmental and social factors should be identified and addressed. These may include current access to the toilet, i.e. if this is upstairs and the individual cannot manage stairs, or poor mobility, which requires walking aids and can these aids be accommodated in the toilet. The patient may have poor dexterity, eyesight, or cognitive issues meaning that they cannot recognise the toilet. Or, it could be even more basic around the patient’s footwear fitting properly, or that they have ingrowing or poorly looked after toenails preventing mobilisation. It is also crucial to consider if aids are the correct size, i.e. toilet frames and seating and, most importantly, if the patient requires assistance and is this available at the appropriate times (Yates, 2018).
 

MEDICATION

Most medication, whether prescribed, over-the-counter, herbal or recreational, can have some effect on bladder or bowel function. There are, however, common drugs that can affect continence, these are outlined in Table 1. This list is not exhaustive and there are many more that can affect continence. Some of these medications can disrupt the normal process of storing and passing urine or increase the amount of urine produced. Others upset the gastrointestinal tract and result in either constipation or diarrhoea. However, medication should not be stopped without consulting a medic or trained prescribing professional.

BASIC INVESTIGATIONS

Bladder/bowel/observational charts

A relevant chart relating to the function of the bladder, bowel, or both (according to presentation of continence issues) is an essential part of the assessment process (Yates, 2019a). To understand any of the charts, the assessor needs to know what would be classed as normal for both bladder and bowel function, and how the individual chart deviates from that normal. Healthcare professionals give bladder charts many different names, i.e. bladder diary, frequency volume charts or micturition chart (Abrams et al, 2002) (Figure 1). There are several different charts available — from simple versions recording output and leakage, to others recording fluid intake and type, voiding urgency, and pad usage (NICE, 2013; UK Continence Society, 2015; Yates, 2018). However, the importance is that the individual completes the information that is relevant to symptoms rather than which chart is used. NICE (2013) recommends that the bladder chart or diary is completed over three days, split into 24-hour periods, with individuals recording voiding patterns for day and night and episodes of leakage ranging from damp to soaking.
 
A bowel diary (Figure 2) is usually completed for a minimum of a week, allowing the individual to record bowel frequency, stool consistency (according to the Bristol stool scale, Figure 3), amounts passed, any leakage or soiling, urgency, any pain/bleeding on defecating, and medication used. These charts can only be used if the individual is capable of independent or assisted completion. If the patient is unconscious or cognitively impaired, an observational chart which can be completed by a healthcare professional/carer may be more appropriate (Figure 4).

Diet and fluids

It is important that the amount and type of fluids consumed are recorded, as this can affect continence. Average fluid intake over a 24-hour period should be approximately 1.5 litres (Fonda et al, 2006; Yates, 2016a). However, individual consumption may vary according to age, state of health, activity and weather. Low fluid intake can contribute to constipation and dehydration, which can lead to bladder urgency and frequency, while excessive intake may increase continence problems and voiding activity (Gilbert, 2006). Caffeine (found in coffee, tea, drinking chocolate, cola, and other carbonated drinks) may have a stimulant effect on the bladder and bowel and can exacerbate bladder frequency, urgency and nocturnal voiding activity, as it is a mild diuretic and can increase the amount of urine produced (Yates, 2019a). This is also true of alcohol. Other fluids, such as fruit juices and herbal teas, can also have an impact on bladder or bowel continence (www.nhs.uk/live-well/eat-well/water-drinks-nutrition/). Individuals who suffer from constipation are advised to eat high fibre foods, while those with faecal incontinence are advised to avoid such foods, caffeine and artificial sweeteners (NHS Choices, 2018). Other conditions, such as lactose, wheat or barley intolerance, should also be ruled out before any treatment.
 

Urinalysis

Staskin et al (2013) identified that a dipstick urinalysis is not a diagnostic but a screening test when undertaken for continence assessment. It can assist to rule out numerous abnormalities, e.g. haematuria (blood in the urine), ketones which may be associated with vomiting, starvation or diabetes, pH where normal range is 4.5–8.0. Acidic urine (below 4) may be associated with starvation, diabetes mellitus or respiratory disease. Alkaline urine (above 8) may be associated with prolonged vomiting, or a vegetarian diet. Calculi can be formed in alkaline urine. Other constituents may include glucose and protein. The test is also a good indicator of an individual’s hydration state. However, diagnosis of UTIs should be based on the patient’s symptoms and not on dipstick urine testing (Public Health England [PHE], 2019a; 2019b). Healthcare professionals should look at individual devolved nation’s current guidance.
 

Post-void residual urine (PVRU)

There are two methods of assessing post-void residual urine (PVRU) volume:
  • Sterile urethral in/out catheterisation (a direct measurement of urine volume)
  • Bladder ultrasound scanning (an indirect estimation of urine volume).
Both of these investigations require a competent, skilled healthcare professional trained in these procedures for implementation and interpretation of results. Individuals who suffer from neurological problems (e.g. stroke, diabetes, spinal injuries) or obstruction of the urethra (due to enlarged prostate or prolapse) are at greater risk of not emptying their bladders completely (NICE, 2015; Yates, 2018; 2019c).
There is no clear consensus regarding the constitution of a normal or abnormal PVRU volume with regards to retention. Volumes of 100–150ml are usually considered significant, but this will depend on total bladder capacity. Healthcare professionals should consider other symptoms/investigations and the patient’s clinical presentation. If the PVRU is above these parameters or the patient has other risk factors, such as straining to urinate, poor intermittent flow, or medical neurological conditions, e.g. spinal injury, spina bifida or diabetes, further investigations and interventions, such as flow rate, urodynamics (which are usually carried out in secondary care) should take place to identify appropriate treatment and management (Home and Community Care [HACC] and Medical Aids Subsidy Scheme [MASS], 2011).
A plethora of evidence suggests that using bladder scanners to identify PVRU volume is preferable over in/out catheterisation, and scanners need to be available within a community setting. Portable bladder scanners are convenient, non-invasive, accurate and carry no risk of urethral trauma or infection associated with urethral catheterisation (Yates, 2016b). They benefit a variety of populations and, if maintained and used correctly, are safe to use and remain the gold standard (Yates, 2016b).
 

RELEVANT EXAMINATIONS

Staskin et al (2013) and NICE (2013) advise that abdominal, neurological, pelvic floor and anorectal examinations are part of continence assessment. While all healthcare professionals may not have the required skills or competency to undertake these examinations, they may well have the skills to do some of the most basic ones, such as a visual examination of the perineum/ anal areas.
The pelvic floor muscles have a multitude of functions, one of the most important being to help maintain urinary and faecal continence (Yates, 2019c). Remember, gaining and documenting informed consent and adherence to infection control guidance should be followed before any examination takes place.
During a visual examination, the dignity of the individual must be maintained, and healthcare professionals should look for signs of anything which may seem abnormal (Table 2).
Asking the individual to tighten (pull in) their pelvic floor muscles may allow the clinician to observe whether there is contraction and thereby evaluate the strength of the muscles (Yates, 2019d). This would be observed by a pulling in of the vaginal muscles in women, a lifting and backward movement of the penis in men, and an anal wink if assessing rectally. An internal examination may be appropriate to identify pelvic floor dysfunction for treatments, and also if there is considered constipation or fullness of the rectum, but only by those competent in the skill.
 

CONCLUSION

Assessment of continence needs is a complex skill which involves understanding the condition and impact it has on the individual and their family. The aim of assessment is to successfully determine the type of presenting continence issue before developing a patient-centred treatment plan. This treatment plan should always start with conservative management therapies, which will be discussed in the next article in this continence clinical skills series.  
 

KEY POINTS

  • Assessment of continence problems should be undertaken by an experienced professional, in line with recommended minimum standards
  • At initial assessment the type of continence suffered should be identified, i.e. bladder, bowel and/or both, as well as the duration of the problem
  • Asking specific questions relating to continence status and listening with empathy is vital to identify type of incontinence and subsequent treatments
  • Symptoms should be recorded as they present. There are many assessment tools and validated symptom profiles/quality of life tools available
  • It is imperative that any healthcare professional undertaking an initial continence assessment understands how health conditions affect continence
  • Environmental and social factors should be identified and addressed
  • A relevant chart relating to the function of the bladder, bowel, or both (according to presentation of continence issues) is an essential part of the assessment process
  • The aim of assessment is to successfully determine the type of presenting continence issue before developing a patient-centred treatment plan.

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This piece was first published in the Journal of Community Nursing. To cite this article use: Yates A (2021) Clinical skills. Part 2: Continence assessment and investigations. J Community Nurs 35(2): 30-37


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