Bladder and Bowel Learning Resource

The urinary tract is the body's drainage system for removing urine, which is made up of waste and fluid.

Micturition

The bladder is a muscular sac, located in the pelvis. The bladder is connected to the kidneys by two tubes called ureters. Each day the kidneys filter about 170 litres of blood, from which they produce about 2 litres of urine, which flows down the ureters to the bladder.

The flow of urine in both men and women is controlled by the internal and external urethal spincter. Control of the internal spincter is involuntary, control of the external spincter is voluntary.

Urine flows down the ureters and collects in the bladder. As the bladder dills it expands, and as the surface starts to stretch. Receptors in the surface send a signal to the brain to indicate that the bladder is filling, and as it approaches its maximum capacity this generates a feeling of discomfort.

Eventually the need to urinate becomes urgent and the brain sends a signal to the sphincter muscles to relax and urine is released from the bladder. The bladder empties and process is repeated.

Kidneys 

The kidneys are two bean-shaped organs that filter waste products, chemicals and unneeded fluid from the blood and produce urine. Located just below the ribcage on either side of the spine, they filter about 170 litres of blood a day, which produces 1.5 to 2 litres of urine. 

Ureters

Ureters are thin tubes of muscle that carry urine from each of the kidneys to the bladder. 

Bladder 

Located in the pelvis between the pelvic bones, the bladder is a hollow, muscular, balloon-shaped organ that expands as it fills with urine. Sitting in the bladder, the trigone is a triangle shaped smooth muscle that contains the ureteric and internal urethral orifices.

A bladder can hold around 400-600mL of urine.

The bladder empties five to eight times a day.

How often an individual needs to urinate depends on how quickly the kidneys produce the urine that fills the bladder. 

As the bladder fills it expands, and as the surface starts to stretch, receptors in the surface send a signal to the brain to indicate that the bladder is filling. As it approaches its maximum capacity this generates a feeling of discomfort. The bladder is emptied through the urethra, which is located at the bottom of the bladder.

Three sets of muscles work together to keep urine in the bladder:

1. muscles of the urethra 
2. bladder neck, composed of the second set of muscles called the internal sphincter 
3. pelvic floor muscles, also known as the external sphincter, surround and support the urethra. 

When it's time to urinate, the brain signals the muscular bladder wall (detrusor) to tighten, which squeezes urine out of the bladder. The sphincters then relax allowing urine to exit the bladder. 

The digestive system 

Food moves down the oesophagus from the mouth and into the stomach, which it mixes with the digestive juices and enzymes. After a period of time the food passes into the duodenum where most of the chemical digestion takes places. Muscles push the semi digested food into the small intestine for further mixing.

The walls of the small intestine have blood vessels where nutrients are absorbed into the blood stream. The food is pushed through the small intestine into the large intestine, where any remaining nutrients are absorbed along with any excess water. As this happens the food is turned into a solid and formed into a stool which is expelled from the body during a bowel movement.

Peristalsis is the process by which food moves through the intestines. This is done by muscles located in the walls contracting in waves and pushing the food along. Here, a partially formed stool can be seen moving along the top section of the large intestine.

Food is moved through the different sections of the digestive tract by a process called peristalsis, which is a series of wave-like muscle contractions. It usually takes between 24 and 72 hours for food to move through the digestive system. The sections are separated by bands of muscles, known as sphincters, which are valves that control the movement of food from one area of the digestive tract to another. It's important that the food stays in each of the sections long enough for the gut to absorb fluid and nutrients before expelling it as waste. 

The small intestine (small bowel) 

The small bowel is about six to eight meters long and two centimeters wide and is comprised of three parts: 

1. duodenum 
2. jejunum 
3. ileum. 

Food passes from the stomach through each of these three parts. The purpose of the small intestine is to absorb nutrients and much of the fluid from foods. As food moves from the small intestine to the colon it has a porridge-like consistency. 

The colon (large intestine) 

The colon, or large intestine (also known as the large bowel), starts at the final portion of the small intestine and ends at the rectum. The colon is about two meters long and six to seven centimeters wide. It is made up of the caecum, ascending, transverse, descending and sigmoid colon. 

The colon is host to a countless number of micro-organisms that support the processing and elimination of waste. It can take between 12 and 48 hours for food to make its way through the colon. 

The rectum and anus 

Once food has passed through the bowel the waste moves to the rectum which stretches, triggering a message to the brain to say that the rectum is full and needs to be emptied. The pelvic floor muscles ensure that the anus remains closed until the person is ready to open their bowels. The nerves can usually tell the brain whether it’s wind or stool that is filling the rectum. 

For the bowel to function properly it needs: 

• the nerves of the rectum and anus to be sending the correct messages to the brain so that it can sense when stool or wind arrives in the rectum and can transmit messages to the muscles to hold it in 
• the internal and external anal sphincters to be working 
• stools which are not too soft or too hard. 

Normal bowel function 

The frequency and consistency of bowel movements will vary from person to person. Frequency averages between three times a day to three times a week, with the stool being soft and easy to pass. 

Stool consistency is usually measured using the Bristol Stool Chart and ideally should be between three and four. 

Lewis SJ, Heaton KW (1997) Stool form scale as a useful guide to intestinal transit time. Scandinavian Journal of Gastroenterology 32: 920–4

A good position on the toilet is when knees are higher than hips (unless recent hip surgery), leaning slightly forward and with the elbows on knees, relax and breath easily and do not strain. 

See: RCN (2019) Management of Lower Bowel Dysfunction, including Digital Rectal Examination and Digital Removal of Faeces

Incontinence is a common problem, with urinary incontinence being more common than faecal. There are a number of different types of urinary incontinence, which are described below. 

The main types of bladder problems are: 

• urgency urinary incontinence - an involuntary leakage of urinary accompanied or followed by the feeling of urgent need to void
• stress urinary incontinence - an involuntary leakage of urine on exertion, such as coughing, sneezing or exercising
• mixed urinary incontinence - both urgency and stress symptoms 
• nocturnal enuresis - involuntary loss of urine during sleep 
• leakage following passing urine and continuous urinary leakage - these are symptomatic forms of incontinence 
• overactive bladder - (may not be incontinent) characterised by the storage symptoms of urgency, usually with frequency and nocturia (waking to pass urine) 
• neurogenic bladder dysfunction - urinary bladder problems due to disease or injury of the central nervous system or peripheral nerves involved in the control of urination. 

Stress incontinence 

Stress incontinence is the involuntary loss of a small amount of urine when pressure increases in the abdomen, for example when coughing or sneezing. It is a problem that predominantly affects women. 

What causes stress incontinence?

Weakness may be caused by a variety of factors, including: 

• surgery - particularly in men following prostate surgery 
• pregnancy and childbirth 
• obesity 
• menopause 
• chronic cough 
• chronic constipation.

What can be done? 

Pelvic floor exercises, vaginal weights, surgery, oestrogen, washables pants or disposable containment product as a last resort. 

Passive incontinence 

When a person feels no urge to open their bladder or bowels. They are unaware that the bladder or rectum is full and ready to be emptied and cannot consciously control their bladder or bowel movements, therefore urine or stools can pass without their knowledge. 

Additional causes of incontinence in men

• Prostatitis - an inflammation of the prostate gland
• Prostate cancer - this is treatable when identified early.

The prostate is approximately the size of a walnut and surrounds the urethra just below the bladder. Its main function is to secrete prostate fluid, one of the components of semen. The muscles of the prostate gland also help propel this fluid into the urethra during ejaculation.

Men can suffer from prostatitis, an inflammation of the prostate gland.

Symptoms can include:

• pain in pelvis, genitals, lower back and buttocks
• frequency of urination
• pain when urinating
• difficulty urinating and “stop-start” peeing
• pain when ejaculating
• tiredness, aching joints, chills and fever.

It is important to consult a responsible clinician if these symptoms are experienced.

Benign Prostatic Hyperplasia (BPH)

The prostate gland often enlarges as men get older and, in some cases, it can become problematic. As the prostate enlarges it may cause narrowing of the urethra. The bladder then needs to contract harder to squeeze urine out. This can cause the bladder to weaken and lose the ability to empty completely, causing overflow incontinence.

BPH can be managed with lifestyle changes, medication and sometimes surgery.

Symptoms:

• the need to urinate more frequently, often at night
• difficulty starting to pass urine
• weak flow
• feeling the bladder has not emptied
• taking a long time to urinate.

Normally a General Practitioner will take a full history of symptoms and perform an examination. They will request a prostate specific antigen (PSA) blood test and carry out a digital rectal examination.

Other factors affecting both men and women

Functional incontinence is where a person is usually aware of the need to urinate, but for one or more physical or psychological reasons they are unable to get to the toilet.

People with dementia may be aware of the need to go to the toilet but may not be able to express this need. There could be a noticeable change in behaviour, such as agitation or restlessness. They may have forgotten where the toilet is or be in unfamiliar surroundings.

Physical problems such as poor eyesight, mobility or dexterity can all lead to difficulty accessing the toilet. Fear of falling, depression and anxiety can also be factors, as well as environmental factors, such as poor lighting, low chairs, stairs or steps and unusual surroundings. Inadequate toilet facilities or a person's fear of using them can also contribute to someone being incontinent.

Incontinence can be a sensitive subject for many people. Often it is associated with shame and guilt. But the more that is understood about the condition, for instance knowing that incontinence is a common problem that is not restricted to older people, the more confident you will feel discussing the issue and supporting the individual. 

Breaking down barriers 

To support people with incontinence effectively, you need to improve your knowledge. With the right information and advice, you can provide people with support and guidance tailored to their needs.

Beginning the conversation 

When raising the topic of incontinence with a patient for the first time, you should aim to achieve three things: 

1. Identify whether there is a continence issue 
2. Does the individual or their carers perceive it to be a problem? 
3. Encourage the individual to discuss their anxieties and what support they need. 

The following tips might help: 

Are you the right person to talk to? 

Consider whether the person needs to be referred to someone with more specialist knowledge. 

How will they respond?

It may be uncomfortable for the person to discuss their incontinence with you, so their response may be one of embarrassment and frustration, even anger. If you can anticipate what their reaction will be, then it can help you to work more effectively with them. 

When is the right time? 

Knowing when to raise the subject is important; it is best done when the individual is calm and can focus on what is being said. Be aware of cues that might indicate that the person wants to discuss something with you. This might be something like "I'm slightly worried about going out and don't take my water pills." 

What tone should I use?

You should use an empathic, matter-of-fact tone of voice. If you feel uncomfortable, don't let this show as it can make the person uncomfortable too. 

Living with incontinence can be challenging. People with the condition may feel uncomfortable discussing it with others and may be embarrassed to admit they have a problem, which can result in them not getting the support and advice that could improve their quality of life. 

The nature of the condition means that the person lives with the fear of having “accidents”, particularly in public, which can lead to feelings of shame and embarrassment resulting in social isolation. 

“My wife would be horrified if she knew she had been incontinent. She has always been so immaculate and proud of her appearance”- Husband whose wife has dementia

"The staff are always so busy, and I feel like a nuisance when I press the buzzer. I don’t want to have an accident. That would make more work for them”– 95-year-old inpatient  

'Over time incontinence leads to a curtailment of daily activities e.g. going out, shopping etc. which decreases self-esteem' (Cartwright R, Srikrishna S, Cardozo L, Robinson D. Validity and reliability of the patient’s perception of intensity of urgency scale in overactive bladder. BJU International. 2010)

Support 

Many health care professionals lack the time and understanding to support people with incontinence effectively, which can lead to individuals being given inappropriate advice. Informal carers can feel overwhelmed and stressed and the daily management of incontinence can feel like a constant cycle of changing and washing. However, by introducing a continence strategy the individual, health care professional and informal carers can gain more control, as well as reduce the workload and enhance the quality of care provided.  

Ability to communicate 

Many people find it difficult to communicate the need to go to the toilet. They may: 

• be unable to express need for the toilet verbally due to aphasia or dysphasia 
• lack the language skills to describe need, for example, they may speak no English or have limited vocabulary 
• may use Makaton or other sign language to express need, requiring other people to understand 
• may not be able to read, recognise or see signs to toilet facilities 
• have speech which may be difficult for others to understand if slurred or words are confused.

These may be exacerbated if the person is stressed because of the difficulty in making others understand. 

The assessment process should be able to identify how a person communicates. Body language is a useful tool for identifying the need in a person with learning or cognitive difficulties. Carers or relatives may easily spot when an individual wants to go to the toilet just by the change in their body language. 

Some people communicate using low tech aids, such as communication books, signs, picture symbols or augmentative and alternative communication aids (electronic talkers).  

However, by simply taking the time to understand how each individual communicates, (they may have unique signs) you can start to recognise when they want to go to the toilet.  

Anxiety 

Many people with incontinence feel anxious about going to the toilet and this can cause them unnecessary stress. They may feel: 

• embarrassed at time and frequency when at work 
• pressure as some employers have strict monitoring of toilet breaks 
• fear and stress about availability and accessibility of toilet facilities 
• worried about being disturbed or overheard 
• scared others may notice them having frequent toilet breaks 
• fear of having accidents. 

Attitudes 

If a member of staff has a negative attitude it is distressing for the person who is incontinent and can prevent them from discussing their problem in an open and supportive way. No one enjoys handling other people’s urine and faeces, but as a nurse the member of staff has a responsibility not to allow personal feelings to get in the way of providing dignified and compassionate care. 

Comments like this are unacceptable and unprofessional and should be addressed under a disciplinary discussion. 

Dignity 

"Dignity is concerned with how people feel, think and behave in relation to the worth or value of themselves and others. To treat someone with dignity is to treat them as being of worth, in a way that is respectful of them as valued individuals" 

Dignified care should be person-centred and not just focused on tasks and processes. An important element of care is to be aware of and sensitive to the features of a person’s life, including their values, feelings and beliefs. Being in need of support, both physically and emotionally, can make anyone vulnerable. 

You may find the following resources useful:

RCN - 'How would you feel?' video

Dignity, Privacy and Confidentiality 

6C's

The daily management of incontinence can be stressful for individuals with the condition, so any advice and support you can offer them will be invaluable. 

"My goal is to get to the bathroom on my own and to be able to wipe my own bottom”  - (38-year-old stroke patient) 

It is important to remember the 6Cs of nursing when managing individuals with incontinence: 

• be compassionate. Incontinence can be a sensitive issue for patients to discuss and uncomfortable to deal with on a day to-day basis 
• manage a patient’s continence needs competently 
• communicate effectively to enable the person to get their needs and wants met 
• be courageous. Overcome your own issues and concerns about supporting a person with incontinence 
• make a commitment  to manage and support the person the best way you can using all your knowledge and skills
• meet the care challenges of incontinence head on. 

By keeping the 6Cs at the forefront of management of individuals with incontinence, you may find that the experience becomes positive and meaningful where the patient feels valued and is given the tools to manage and cope with their incontinence. 

Assessment tools

There are different types and causes of incontinence. A continence assessment helps to determine what the problem is and what treatment is required. It includes details of the individual’s signs and symptoms and a physical examination may be indicated. 

Further resource: RCN (2020) Genital examination in women

Quality of life questionnaires

There are questionnaires that can help to measure quality of life, developed by the International Consultation on Incontinence Questionnaire (ICIQ) group. These tools are specifically related to incontinence and enable people to report their own perspective of their situation.

Further resource: ICIQ - UI short form

Symptom profiles to help diagnose the bladder problem.

Pathways

Care Pathways support health care professional and patient to take a stepped approach after diagnosis, which is evidenced based.

Further resource: Urinary continence assessment, treatment and management - using the Colley Model. 

The consent of the individual to an examination must be gained; however, if there is any doubt about the individual’s capacity the intervention should only be undertaken in the person's best interest. It is important to identify why the person is seeking advice at this time.  

Points to consider include: 

• how often the person goes to the toilet to urinate and defecate and whether this is a change to their normal routine 
• current or previous medical history (including pregnancy and urine infections) 
• possibility of physical or sexual abuse, including Female Genital Mutilation - FGM 
• a rough estimate of the amount of urine passed 
• visual description of the faeces (normally based on Bristol Stool Chart) 
• if there is leakage, whether it is urine or faeces 
• information about diet and fluid intake 
• any medications being taken (both prescribed and over the counter) 
• lifestyle factors, including recreational drugs, alcohol, smoking and weight 
• ability – for example, whether the person can feed, dress and bathe on their own.
• mobility – physical or environmental factors 
• capacity – does the person recognise the need to go to the toilet or do they forget where the toilet is?

Bladder diary

Having a 3-day bladder diary with information about the type of drink and the amount in 24 hours can be used to support part of the assessment.

Examples of bladder diary and bowel charts:

Bladder diary

Bowel chart

• do you know the size of the cup/mug is drunk?
• what is type of drink? Is it caffeinated? Or caffeine free as caffeine can irritate the bladder as can fizzy drinks.
• an output of urine, to highlight voiding issue, such as overactive bladder, retention of urine.  

Hydration

Promoting the importance of hydration is key to improving bladder and bowel symptoms. Human beings are made up of 75-80% water. Studies suggest most healthy people should try to drink six to eight glasses of water each day. Water is the best fluid for optimum bladder health, however some people need to drink less water because of certain health conditions such as kidney failure, heart disease and being underweight (Abrams Fluid Intake Matrix guide, 1996).

Tools like the Fluid Intake Matrix can help to support the volume of fluids that a person should be having in 24 hours.

Fluid Intake Matrix

A guide to the volume of fluid required per body weight for 24 hours. Not to be followed if medical condition contra-indicates i.e chronic renal failure.

This matrix is to be used as a guideline and broadly it is suggested that patients fall within a margin of error +/-10%. The guideline applies to body frame and gross obesity should not be taken as a guide for increasing fluid.

Activity levels should not be taken into account.

Reference: Abrams & Klevmar 'Frequency Volume Charts - an indispensable part of lower urinary tract assessment' 1996 Scandinavian Journal of Neurology 179. 47 - 53

Dehydration occurs when the body expels more fluids than it is taking in, dehydration can lead to urinary tract infections which can become severe enough to warrant antibiotics. Longer term dehydration can cause kidney stones and kidney infections. Concentrated urine consists of more solutes which are dissolved particles like sugars which should be expelled as waste, these particles can irritate the bladder causing frequency, urgency and overactive bladder. Added ingredients in fizzy drinks and energy drinks and caffeine in tea and coffee can exacerbate certain bladder symptoms. Acidic foods and drinks, such as lemons, limes, oranges and grapefruit’s, tomatoes and tomato products are also reported to aggravate bladder symptoms.

Dehydration is one of the most common causes of infrequent bowel function and chronic constipation, which results in hard stools which are difficult to pass. Besides water, vegetable juices, clear soups and herbal teas are all good quality sources of fluids. There is evidence suggesting increased water consumption enhances the effects of a high-fibre diet on stool frequency and reduces laxative consumption in adult patients with functional constipation.

Are you drinking enough?

Making sure you are drinking enough fluids can help your recovery and keep you fit and healthy, preventing dehydration.

You should aim to drink at least 1.6 to 2 litres (approx. three to four pints) of fluid per day to stay hydrated. This is the same as around eight glasses or mugs of fluid.

Signs of dehydration can include: a dry mouth or lips, thirst, tiredness, headache, dry and loose skin, and dark coloured or strong smelling urine. 

Use the urine colour chart below to check if you may be dehydrated. If you are concerned please speak to a nurse.

There is a growing body of evidence linking fluid balance with bladder and bowel dysfunction and we now have online hydration toolkits available to support staff in achieving optimum hydration. It can be challenging for some to drink sufficient fluids to achieve optimum hydration and these tool kits have a wealth of resources and guides to support you in clinical practice.

More information related to hydration can be accessed here: 

RCN. Hydration essentials.
NICE (2018) Reducing incidence of Urinary Tract Infections by promoting hydration in care homes.
NICE (2018) Seven glasses a day, keep UTIs at bay.

Red Flags

National Institute for Health and Care Excellence (NICE) guidelines suggest that a referral should be made for urgent or specialist investigation if an individual has any of the following ‘red flag’ symptoms see NICE guidance:

Bladder

• haematuria (blood in the urine) 
• recurrent urinary tract infections (3 or more in last 6 months) 
• loin pain (pain in the lower back) 
• recurrent catheter blockages 
• hydro nephrosis or kidney stones on imaging 
• biochemical evidence of renal deterioration.  

Bowel 

• rectal bleeding 
• mucous present on defaecation 
• altered bowel habit (frequency or consistency) 
• unexplained weight loss. 

Recent travel to other countries (particularly developing countries) should be identified. 

Any possible safeguarding issues should be identified and managed according to local protocols.

Further resources:

NICE. Suspected cancer recognition and referral: site or type of cancer
NICE (2019) Urinary incontinence and pelvic organ prolapse in women: management NG123
NICE (2015) Lower urinary tract symptoms in men: management CG97

Urinalysis

Bladder 

Testing Urine, as part of a continence assessment in line with NICE Guidance.

Reference: Produced by Southern Health NHS Foundation Trust with permission to use

Urinalysis for a Continence Assessment

Bristol Stool Chart 

People have different bowel habits and most who regularly “go” three times a week and pass good stools (not too hard or soft) are considered to have normal bowels. 

To help health care professionals determine what is “normal”, a visual guide was developed to identify the type of stool passed. The Bristol Stool Chart is an assessment tool designed to classify human faeces into seven categories. 

What each type means?

• Type 1-2 indicate constipation
• Type 3-4 are ideal stools 
• Type 5-7 may indicate diarrhoea and a need to empty the bowels urgently 

Treatment

Treatment for bowel incontinence depends on underlying cause and the pattern of the symptoms. 

Trying the least intrusive treatments first, such as dietary changes and exercise programmes, is often recommended. Medication and surgery are usually only considered if other treatments haven't worked. 

Treatment that can help with bowel incontinence includes: 

Dietary changes 

Bowel incontinence associated with diarrhoea or constipation can often be controlled by making changes to the diet. 

Diarrhoea 

NICE provides the following dietary advice to people with diarrhoea associated with bowel incontinence:

• limit fibre intake from wholegrain breads, bran, cereals, nuts and seeds (except golden linseeds) 
• avoid skin, pips and pith from fruit and vegetables
• limit fresh and dried fruit to three portions a day and fruit juice to one small glass a day (make up the recommended ‘five a day’ with vegetables) 
• reduce consumption of fizzy drinks and drinks containing caffeine 
• avoid foods high in fat, such as chips, fast foods and burgers. 

Constipation 

A high-fibre diet is usually recommended for most people with constipation-associated bowel incontinence. A GP can confirm whether a high-fibre diet is suitable. Fibre can soften stools, making them easier to pass. Foods that are high in fibre include: 

• fruit and vegetables
• beans
• wholegrain rice
• whole-wheat pasta
• wholemeal bread
• seeds, nuts and oats
• fluids can help to soften stools and make them easier to pass. 

Pelvic floor muscle training 

Pelvic floor muscle training is a type of exercise programme used to treat cases of bowel incontinence caused by weakness in the pelvic floor muscles. 

Bowel retraining 

Bowel retraining is used to treat people with reduced sensation in their rectum as a result of nerve damage, or for those who have recurring episodes of constipation. 

There are three goals in bowel retraining: 

• to improve stool consistency 
• to establish a regular time to empty the bowels 
• to find ways of stimulating the bowels to empty themselves.

Barriers to maintaining continence

It is estimated that more than three million people in the UK are affected by incontinence which has no anatomical cause. The person may be rendered incontinent because of physical, psychological, emotional, cognitive or environmental factors. Some of these are listed below. 

Learning/cognitive disability 

Learning disability or cognitive impairment needs to be taken into consideration when carrying out a continence assessment. Bowel and bladder control may take longer to develop in individuals with learning disabilities. Specialist continence support for these people can result in them becoming continent. 

Language barrier

We must make sure, wherever practical, that arrangements are made to meet patients’ language and communication needs.

Mobility 

If a person has the ability to know when they need to go to the toilet, but are unable to do so independently, they may experience continence issues. 

For some people, accessing the toilet can be so challenging that using a pad or requesting a catheter is easier than trying to remain continent. If the person is a wheelchair user and needs support to go to the toilet, it can be particularly challenging as help is not always available in a timely manner. 

A full assessment may identify toileting aids and equipment (such as urinals, handrails, commodes and removable clothing) that can support an individual to remain independent and, in some cases, major adaptations such as hoists, downstairs toilet or stairlift may be appropriate.

Environmental factors 

When people are out and about in the community, toilets can often become an issue. The location and accessibility of toilets can be a barrier to continence, and with councils closing more public toilets it makes getting to a toilet even more difficult. 

In general people do not like to be heard on the toilet or may be embarrassed when using public toilets. Often these facilities are not clean and can be unpleasant to visit. If a person does not have a choice in where they go to the toilet, it may become preferable to be incontinent than use an unsuitable bathroom or toilet. 

People with Autistic Spectrum Disorders (ASD) may only be able to use a toilet in the home environment or use certain toilets when they are in an unfamiliar place, so this will need to be planned before going outside of the home. 

Flooring in bathroom areas need careful consideration as certain colours or shiny floors can make the floor look wet and cause problems for people with visual impairments. 

Care homes and hospitals often locate toilets away from main areas and they may be poorly marked or signposted. If an individual cannot locate the toilet or it is too far away, involuntary incontinence may occur. 

Often signage on toilet doors can be confusing, especially for people with dementia. Complicated or modern icons might be used, which some people may find difficult to recognise as the place where they can go to the toilet. 

Other examples of where the environment can make it difficult for people to go to the toilet: 

• poor maintenance of public toilet facilities – wet, dirty floors 
• many accessible facilities need a Radar key to gain access, which can be obtained from the local council 
• poor consideration of space needed by wheelchair users or people with young children in pushchairs 
• doors are often heavy and open outwards, requiring assistance from another person to gain access 
• no hoists or changing plinths in the majority of accessible facilities 
• person has to transfer to the toilet by standing or using transfer aids  
• a limited number of cubicles in men’s toilets and lots crammed into ladies toilets, making it hard to gain privacy if they have diarrhoea or offensive smelling stools or flatulence. 

Assessing an individual for the correct equipment to manage and maintain their continence is imperative. It will require input from a specialist continence professional who may be a nurse or an occupational therapist. 

There is a wide variety of equipment on the market and finding the most appropriate for the individual is vital. The types of equipment may range from raised toilet seats to highly specialised toilets that may include the facility to wash the person. 

Simple things that can help support people with incontinence include: 

• toilet paper is always available 
• the bathroom area is clean 
• toilet doors are able to close 
• sufficient space and access needs to be provided to allow for staff, wheelchairs and other aids.

Clothing 

Clothing can be a barrier to managing incontinence. If a person has poor manual dexterity, they can find it difficult to undo or pull-down garments. There are a number of companies which manufacture clothing that is easy to remove, pull down, etc. For example, skirts with velcro sides, trousers/pants with drop down fronts. These garments look functional and unfashionable or just unappealing and people should seek advice about where they might find clothing that meets their needs and looks nice. As an alternative, it may be possible to alter existing clothing to make dressing and living with incontinence more manageable. 

Equipment and devices 

A number of products are available to help with the management of incontinence. These include: 

• handheld urinals (urine collection bottles) 
• a catheter, a thin tube that is inserted into the bladder to drain urine. It may be used intermittently or on a long-term basis 
• devices that are placed into the vagina or urethra to prevent urine leakage, for example during exercise 
• urinary sheath 
• absorbent products, such as incontinence pants or pads.

Urinary catheters

Following your clinical assessment and collaborative decision making on the need for a urinary catheter consideration then needs to be given on make (potentially guided by local formulary), size (sex, urethral/ suprapubic and clinical assessment) and type:

Indwelling (Short term) – used for 28 days or less

Indwelling (Long term) – used for up to 12 weeks

Intermittent - inserted several times a day, for just long enough to drain the bladder, and then removed

A Suprapubic (SP) Catheter is initially surgically inserted through the skin to the bladder, it is important to check that the catheter is licenced to be used for a SP Catheter.

Further resources

RCN (2019) Catheter care: guidance for health care professionals 
NHS England. Urinary catheter tools  
NHS (2020)Types of urinary catheters 

Toilet Aides

Bed pans

Bed pans are a portable receptacle for bed bound patients. They are often made from a plastic which can be washed at high temperatures or recycled or moulded pulp that can be disposed of after use.  

Positives: low cost, can be reusable and easy to clean. 

Negatives: User may find it uncomfortable to use while lying down. User may need assistance to get bed pan in position.  

Commodes

Commodes are a chair with concealed toilet bowls. Commodes are available with the following features designed to make them comfortable, convenient and stable, such as adjustable height, removable arms, splayed legs and footrests. 

Positives: Discreet, can be placed near the bed for easy access at night, some are suitable to be used as shower chairs or can be wheeled over a normal toilet. 

Negatives: The commode and pale require regular and thorough cleaning and disinfection to prevent cross infection.

  

 

 

 

 

 

 

 

 

 

 

 

Free-standing toilet frame

A free-standing toilet frame is made from a steel frame that locates around the toilet to offer toileting support. A Sani chair is similar but with a toilet seat attached.

Positives: flexible can be altered to be the correct height for the patient. No need for building alterations.

Negatives: not secured to the wall or floor – could tip or cause entrapment. 

 

 

 

 

 

 

 

 

Floor / wall mounted toilet supports

Floor / wall mounted toilet supports are useful where space is limited as they can be folded up out of the way when not required. They are particularly appropriate for users who may be transferring to and from a wheelchair.

 

 

 

 

 

 

Raised toilet seat

The raised toilet seat can be fitted over the existing toilet seat and is secured in place to the toilet bowl with two clamps at the rear, available with or without lid. 

Positives: Easy to fit, available in different heights depending on patient.

Negatives: risk of falls if not fitted correctly.

  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RADAR keys

RADAR keys: The Royal Association for Disability and Rehabilitation, which is now Disability Rights UK, worked in partnership with Nicholls & Clarke, the inventors of the RADAR lock and together they created the National Key Scheme (NKS). The first RADAR locks were fitted in 1981 to help keep accessible toilets free and clean for disabled people.  

Positives: Easily available from most local authorities who will sell or give a RADAR key. 

Negatives: If you are travelling to Europe, the RADAR key will not work so you will need to buy a Euro key 

 

 

 

 

 

 

Bottom wipers

Bottom Wipers are designed to help those who may have limited dexterity or other mobility issues with their personal toilet hygiene, it is a discreet and effective, it is a bathroom aid that can help maintain personal hygiene when reaching becomes difficult. 

Positives: promotes independence reducing cost of carers. Maintains skin integrity by preventing body fluids to damage the skin. 

Negatives: Unable to see if bottom is clean and condition of skin. 

 

 

 

 

 

 

Foot stools

Foot stool are to assist in achieving the 'right' angle when going to the toilet.  When squatting, the puborectalis muscle loosens creating a straight passageway into the rectum.   

Positives: easy and discreet storage when not in use. 

Negatives: risk of falls if person forgets that their feet are raised off the floor.

 

 

 

 

 

 

 

 

 

 

Body suit

Body suit is made in the UK from 100% cotton, which provides the user with exceptional comfort. Cotton bodysuits are the ideal solution to provide extra security for keeping incontinence pads in place whilst also helping to prevent tapes from coming unstuck. The bodysuit features 3 metal steel snaps at the crotch to allow for easy access and fitting. For maximum hygiene, the cotton bodysuit can be either machine or hand washed up to 40 degrees Celsius 

Positives: added security for those worried that incontinence pads may become dislodged or at risk of choking from Superabsorbent Polymer in pads.  

Negatives: Risk assessment may be required if used in patients’ best interest. 

 

 

 

 

 

Male Continence devices 

Male devices are a range of products that men can use as alternatives to absorbent pads. They are divided into two main categories according to their function:  

Some are designed to contain bladder leakage this includes sheaths and body-worn urinals.

Some are designed to prevent bladder leakage – such as the penile compression device or clamp.

Portable urinals for men

These are designed specifically to fit the male anatomy and to be convenient to the user.  

Positives: Male urinals can be put into position by or for the patient as and when required. Some have an option to add a drainage bag.

Negatives: Urinals can be heavy to manage when full and a patient’s hand control is poor, they may need assistance to empty the urinal. Risk of spillage if the patient.

 

 

 

 

 

 

Sheath

Is very similar to a contraceptive condom. It fits over the penis and collects urine as it leaves the body. You may also hear them called Condom catheters and will be connected to a leg drainage bag or a night drainage bag.

Positives: Sheaths are supplied in a range of lengths and sizes. Ensure a size that provides a secure fit without being too tight. If the man has a shortened penis (this is common after some treatments for prostate cancer) there are sheaths available in shorter sizes with the adhesive band nearer the tip of the sheath and extra thin sheaths. 

Negatives: They don’t work well if the man has a short or retracted penis and in which case products designed specifically for this purpose may work better.  

 

 

 

 

 

 

 

 

 

 

Devices for penile retraction

Pubic pressure urinal

This is a reusable product made out of latex, it consists of a ring which is held in place with straps or underwear in the same way as body-worn urinals but the ring is held firmly in place against the pubis and applies pressure to help the penis to protrude.  

Positives: Pubic-pressure devices are effective in men with a retracted penis. They are available as single devices or integrated in underwear  

Negatives: they require specialist assessment for the correct size and fit, as when the fitting is incorrect, these devices can cause tissue damage. 

Male external continence device

This is an innovative external continence device which enables men to manage their own urine output with confidence. It offers an effective longer lasting alternative to sheaths and pads and can be used for up to 48 hours. 

Positives: Good for men with a retracted or shorter penis. Longer wear time than standard sheaths up to 72 hours.

Negatives: When first using the device the device, the body will need to get used to the hydrocolloid in the adhesive. This phase normally takes 24-72 hours after the first application depending on the condition of the skin (this is not always visible). During this period the device the device, may need to be replaced more often, whilst the hydrocolloid absorbs any excess moisture. 

Penile pouches / Male urinary pouch external collection device

These are small urine collection bags with an adhesive ring that is stuck onto the pubic bone around the penis. The hole can be cut to size to fit different penis widths. 

The pouch collects urine and there is a tap at the bottom to allow the user to empty it into a toilet or urinal.

Positives: They are usually disposable and can be worn for 24-48 hours. 

Negatives: it may be necessary to shave or trim the pubic hair in order to ensure that the adhesive can hold the pouch in place properly. It is likely that they work better in a standing position rather than seated. 

 

 

 

 

 

 

Female continence devices

Portable urinals for women

These are designed specifically to fit the female anatomy and to be convenient to the user.  

Positives: Most female urinals have a flat narrow end which can be easily put into position underneath the patient. This can be particularly useful if the lady is not very flexible and has difficulty moving her legs apart. 

Negatives: Urinals can be heavy to manage when full and a patient’s hand control is poor, they may need assistance to empty the urinal. Risk of spillage if the patient has to lie down.

 

 

 

 

 

 

Funnel

A funnel is designed for women to use out of bed. It is recommended that the woman sits on the edge of a chair/bed or stands and holds the funnel in place.  

Positive: The funnel is moulded from a soft plastic, which comfortably seals with the skin and helps minimise leakage. 

Negatives: must be used with a drainage bag, leg bag or bottle bag.

 

 

 

 

 

Female hydrophilic urine director

Allows a woman to pass urine while standing or in a wheelchair.

If current local formulary devices are not suitable for the patient, you may consider contacting your local bladder and bowel service through your local NHS trust. Some items may be available to purchase.

Body-Worn Urinal (BWU)

Is a general term used to describe a wide range of male devices which are mainly reusable (although they can have a disposable part such as a leg bag) that are designed to collect urine as it leaves the body. They offer an alternative to a disposable sheath system and are secured in place using either straps, specially designed underwear or occasionally adhesive. 

Positives: They are good for men who would like an alternative to a sheath or would like to try a reusable product. As 

many BWU are reusable, men who have to pay for their products may find one a cost-effective option for at least some of the time. It is durable, made of high-quality materials and easy to keep clean. If handled maintained properly, the system can last for months.

Negatives: They do not work well for men with a retracted or shortened penis, if this is the case try products specially designed for this purpose.

Male urine collection system brief

These are a unique and innovative male urinary continence management system and has been designed to provide men with comfort and independence.

Positives: soft cotton pants, reusable.

Negatives: measurement maybe required.

 

 

 

 

 

 

Cotton boxer brief

The cotton boxer-briefs discreet and secure hold a plastic ergonomic curved receptacle inside a front pocket that channels urine into a 500ml reusable collection bag. No tubes or straps are required - just attach the bag directly to the receptacle through the briefs for hours of use without maintenance or changing. 

Positives: cotton pants, reusable.

Negatives: requires flaccid penis to dangle over testicles and reasonable dexterity for fitting.

 

 

 

 

Penile compression device

A penile compression device (commonly called a clamp) is a small reusable device that is available in several different designs. They all work by compressing or squeezing the penis, either by acting as a clamp that is closed over the penis, as a strap that goes around the penis or occasionally an inflatable cuff.

Positives: clamps work well for active men who want a discreet product. The man must have normal feeling in his penis and be able to remember to release the device regularly (around two hourly).  

Negatives: Clamps can be uncomfortable to wear and can reduce blood flow in the penis and some men find they are unable to tolerate them.

 

 

 

 

 

 

 

 

 

 

 

Female continence devices

Internal vaginal / Intravaginal devices

These are placed inside the vagina to support the bladder neck thereby reducing/preventing stress incontinence. Some devices are also believed to compress the urethra which also helps to reduce stress incontinence. 

Positives: Devices are purpose-made, from a range of materials including polyurethane foam and silicone and are usually only available in one size. They can be either disposable or reusable. 

Negatives: Some patients report discomfort and pain, vaginal soreness or irritation, bleeding and urinary tract infection with some types of devices. Some women find fitting the devices problematic, especially those with altered vaginal anatomy secondary to childbirth or surgery. Women still have to wear a pad as they may find that their incontinence improves but continue to suffer from some urinary leakage.

  

 

 

 

 

 

 

 

 

 

 

Female External Catheter

This is a non-invasive urine management device. The flexible and contoured catheter is positioned between the labia and gluteal muscles, remaining completely external it is connected to a low-pressure and continuous suction vacuum system, pulling urine away from the body into a collection canister.  

Positives: reduces the need for indwelling catheterisation and therefore minimises the risk of CAUTI’s.  Can be used as an alternative to absorbent pads.

Negatives: patient must be in a bed or chair whilst product is in use.

 

 

 

 

 

 

Bowel Management

Anal plugs prevent the uncontrolled loss of solid stool. Because of its small size, the anal plug can easily fit into your pocket or handbag. It cannot be seen by others as it is worn inside the body. By protecting against leakage, the anal plug gives the person confidence to participate in activities where you need to feel secure, such as swimming. Unpleasant odours are also avoided as the plug retains stool in the bowels. 

How does Spinal Cord Injury (SCI) affect Bowel function?

Damage to the spinal cord has a profound impact on all bodily systems including the function of the large bowel and on maintenance of faecal continence.

The effect of SCI on bowel function is individualised and dependant on many factors including:

• neurological deficit – i.e. level of injury and completeness of injury
• psychological factors associated with adjustment to SCI
• body image
• environmental factors
• care support available.

For all SCI individuals, the enteric nervous system remains functionally intact. Therefore, peristalsis continues, but as there is little or no co-ordination from the brain and spinal cord, peristalsis is less effective, and colonic transit time is extended. This leads to a drier stool and an increased likelihood of constipation.

In the majority of cases, the descending input from the brain to the colon and ano-rectum is lost. These changes result in the loss of sensation of the need for defaecation, loss of voluntary control of defaecation and loss of the brain’s influence over reflex activity.

Sensory and motor control of the ano-rectum is lost leaving the individual unable to feel the need to evacuate the bowel or to control the process of defaecation.

Without intervention, the SCI individual will be incontinent of faeces and chronically constipated.

This will lead to secondary complications such as

• overflow diarrhoea and faecal impaction
• loss of appetite
• increased risk of pressure ulcers and moisture lesions
• abdominal pain and increased spasm
• autonomic dysreflexia (this is a risk for individuals with spinal cord lesions at T6 or above)
• damage to the colorectal structures – common problems include mega colon, haemorrhoids, anal fissure and rectal prolapse
• abdominal distension leading to respiratory difficulty
• bladder dysfunction
• faecal vomiting
• perforated bowel.

The function of the lower bowel must be effectively managed to allow the SCI individual to maintain continence and to minimise associated health problems.

Types of SCI bowel Dysfunction

Reflex bowel

Reflex bowel occurs in injuries where the nerves in the reflex arc from the cord to the colon and anorectum are not damaged. This usually occurs in individuals who have an injury above T12.

Because the reflex arc is not damaged, there is reflex activity which can be utilised for effective bowel emptying using digital rectal stimulation (DRS) and rectal stimulants (suppositories or micro enemas)

Areflexic bowel

Injuries which result in damage to the reflex arc between the spinal cord and the colon and ano-rectum result in an areflexic bowel (this is sometimes referred to as “flaccid”).

These are usually injuries to the first lumbar vertebra (LI) and below.

This results in slow stool propulsion through the descending and sigmoid colon and a high risk of faecal incontinence through the lax anal sphincter and pelvic floor. The management for this type of bowel is based on a Digital Removal of Faeces (DRF), therefore a slightly firmer stool which is easier to remove digitally is advised (Bristol Scale 3).

Incomplete neurogenic bowel dysfunction

Some individuals with incomplete lesions may have a degree of preserved sensation or residual voluntary control.

They may or may not have:

• an efficient defecation reflex
• sensation or even pain
• awareness of ‘full’ & ‘empty’
• voluntary defecation inhibition. 

However, this may not be sufficient to enable reliable bowel control.

Conus and Cauda Equina Injuries

Individuals with Conus Medullaris Injuries or injuries to the spinal nerves forming the Cauda Equina will usually experience Lower Motor Neurone bowel function because these reflex centres are located in the conus.

Further resources

• Harrison P, Lamb A. (2006): Autonomic Dysreflexia. In Harrison P (ed) Managing Spinal Cord Injury: Continuing Care, Spinal Injuries Association, Milton Keynes.
• Multidisciplinary Association of Spinal Cord Injured Professionals 2012 Guidelines for management of neurogenic bowel dysfunction in individuals with central neurological conditions.
• In 2018, A Patient safety alert was raised, as it was identified staff lacked training and experience in providing bowel care to patients at risk of autonomic dysreflexia. See: NHS. Resources to support safer bowel care for patients at risk of autonomic dysreflexia.

An overview of conventional SCI Bowel Management

For more information please see Royal College of Nursing (2019) Bowel Care. Management of lower bowel dysfunction, including digital rectal examination and digital removal of faeces, London: RCN.

Taken from: Bowel Management for Individuals with an Established Spinal Cord Injury (SCI) An Introductory Document for Healthcare Practitioners in the Hospital Setting
Lisa Lewis RGN & Paul Harrison, RGN, 2018

Case Study 1 - Lily Jones

Names used are fictitious

“Patient, Lily Jones, 78 is referred to the district nurses with worsening urinary incontinence.  She has recently moved into a residential home after the death of her husband who was her main carer. She has rheumatoid arthritis, with pain in most joints and chronic back pain and is using opiate based medication. She is constipated. She has been doubly incontinent at times. Her urine is stinging when she goes. She has been avoiding drinking as she has been struggling to get to the toilet independently and her clothes and furniture have been getting wet.”  

What further information would you need to assess if Lily has a UTI? 

You will need to find out the following:

• does she have a temperature? 
• is she needing to pass urine urgently or more frequently than usual? 
• does she have pain or a burning sensation when passing urine? 
• does she have any blood in her urine? 
• does she have any pain in lower abdomen? 
• is she feeling tired and unwell? 
• is there new onset or worsening incontinence? 
• does she have increased voiding at night? 

You find out:

• Lily’s temperature is 37.6 
• she has increased urinary frequency and urgency 
• she has pain in her lower abdomen 
• she has been feeling tired 
• she needs to get up 5 times at night instead of twice.  

Does Lily have an upper or lower urinary tract infection?

Lily has a lower urinary tract infection.  

What else could you do for Lily to improve her continence and reduce the risk of her getting a UTI again in the future? 

Please note: this is not an exhaustive list.

• once UTI has been treated with antibiotics, arrange for a continence assessment to be done 
• support Lilly to improve her constipation by reviewing her dietary and fluid intake (see fluid matrix chart in hydration section) 
• review the need for laxatives as appropriate 
• review her pain management to see if an alternative to an opiate based painkiller could be found.  
• consider a referral to a physio to see if her mobility can be improved 
• consider the need for psychological support for her low mood due to her recent bereavement and loss of her home. This may be impacting on her motivation and appetite
• ensure she has easy access to a toilet or commode.

Case study 2 - James Morrison

Names used are fictitious

James Morrison is an 89-year-old gentleman with a history of dementia and benign prostatic hyperplasia. You are visiting his wife for a wound dressing and she explains he has been feeling unwell.  

He has been vomiting, is off his legs, is not eating and struggling to keep fluids down. He is normally fully mobile but is in bed and his wife says he seems more confused than normal.  

What further information would you need to assess James? 

You will need to assess the following (please note: this is not an exhaustive list):

• baseline observations to include  
• pulse 
• respiration 
• oxygen saturations
• temperature 
• blood pressure
• does he have any back pain / muscle aches? 

You discover:

• he is complaining of back pain 
• he has a temperature 38.3 
• his BP is 90 / 54 pulse 134 
• he has not passed urine since last night.

What life threatening conditions would you be concerned about?  

James could have a possible upper urinary tract infection and/or sepsis.

What further action would you take?  

Ring 999.