Continence assessment guidelines

The diagnosis must establish the type and cause of the existing condition.

Duration of present problem

When did the problem start – was it associated with a specific event, e.g. childbirth, admission to residential care, emotional trauma, bereavement, surgery?

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Obstetric history

Women who are at risk of having bladder problems post-natally are those who have had:

• large birth weight baby ( over 8.5 lbs)
• instrumented delivery
• epidural anaesthetic
• babies with large head circumference
• prolonged second stage of labour
• perineal tears (grade 3 or 4)

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Previous medical history

Could an underlying disorder be causing the bladder dysfunction e.g. Parkinson’s disease, multiple sclerosis, diabetes, stroke?

However, do not assume that this is the case. Always complete an assessment in full before diagnosing the problem.

Ask yourself is there a specific problem with cognitive impairment or motivation? Or, has the client had previous investigations or surgical intervention for their bladder/bowel dysfunction?

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Physical assessment

Mobility and dexterity

How mobile is the client – do mobility problems affect the client’s ability to control their bladder – might it affect management?

How dextrous is the client – do dexterity problems affect the client’s ability to control their bladder – might it affect management?

Perhaps referral for physiotherapy or occupational therapy would be appropriate.

Drug therapy

What medications is the client prescribed – e.g. diuretics, sedatives. Could they affect the client’s continence or ability to control their bladder? Discuss with GP.

Also take note of any over the counter preparations that they may be taking and find out whether they are taking drugs prescribed to alleviate bladder/bowel dysfunction, eg. anticholinergics, laxatives, etc.

Fluid intake

The recommended fluid intake is six to eight mugs (1.5 – 2 litres) per twenty four hours.

Less than this amount may lead to concentrated urine which irritates the bladder mucosa and can make them more susceptible to urinary tract infection. Therefore advise increasing their fluid intake.

Conversely, more than ten cups of fluid per twenty four hours may be exacerbating the condition; therefore reducing their fluid intake may help.

Alcohol and drinks containing caffeine, eg. tea, coffee and cola, may irritate the bladder and should be avoided if symptoms of urgency are present.

Pattern of micturition

Urinary output:

Normal frequency - 4-8 voids per 24 hours. Maximum volume 400-500mls - Nocturia <2.

Completion of an intake and output chart over three days will be helpful to get an accurate picture of the times and volumes of urine passed, and the number of incontinent episodes. Where greater volumes are passed at night, this may indicate cardiac problems.

Degree of incontinence:

How wet is the client? Does he/she have damp pants, wet pads or wet clothing, eg. light, moderate or severe incontinence.

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Physical examination

Vaginal and pelvic floor assessment

In some post-menopausal women de-oestrogenisation of the vaginal mucosa (Atrophic Vaginitis) can lead to symptoms of frequency, urgency and urge incontinence. The client may complain of vaginal dryness.

Uterine prolapse, cystocele or rectocele can lead to stress incontinence and an assessment of pelvic floor function should be carried out. If the Practitioner is not skilled in this procedure referral to GP for vaginal examination may be appropriate.

Bowel assessment

Is the client constipated? Constipation can be a cause of bladder weakness.

Skin condition

This may affect current management and could have a bearing on a future management plan.

Urinalysis

Urinary tract infection can cause urgency, frequency and urge incontinence.

Multistix urinalysis will indicate if infection is present. If nitrites, leucocytes, blood or protein are positive, an MSU should be obtained. The presence of blood in the urine may also indicate other pathology, eg. stone or tumour, and referral to GP is recommended.

Psychological assessment

Lack of client motivation may affect treatment outcomes. How does the client feel about their problem? Is it socially disruptive and does it affect client, family and carers? Does the client’s mental health problem affect their understanding and perception of their condition? Poor cognition may affect the client’s ability to comply with treatment/management plan.

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