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Guest Editorial: The Last Taboos — Urinary and Fecal Incontinence
This issue continues the OWM tradition of focusing the December articles on incontinence and features the work of incontinence specialists, including several of my colleagues. The articles address both urinary and fecal incontinence.
Urinary incontinence (UI) can affect 10% to 35% of community-dwelling adults and more than 50% of residents in nursing homes or those receiving skilled nursing visits at home.1 The disorder is more prevalent among women than among men and incidence increases with age. Fecal incontinence (FI) – the inability to control liquid or solid stool – and incontinence of flatus (defined as anal incontinence2) occur in about 1% of elderly persons and in 23% to 66% of nursing home residents.3 Urinary and fecal incontinence in the nursing home or home care setting often occur together (“double incontinence”) and are more severe in these settings than in ambulatory care patient settings; these conditions are associated with increased morbidity and have major adverse social, psychological, and economic impact on society.4 The stigma surrounding bladder and bowel control problems and the fact that people have many misconceptions about these conditions prevent patients from seeking care – a common consequence of conditions that have greater stigma (and often are less life-threatening) is that they tend to take a much longer time to be declared to a physician or nurse and even longer to family, friends, and others.5 Hence, UI and FI continue to be taboos for medical professionals and society in general.
The articles in this issue address urinary problems, UI, and refractory overactive bladder (OAB); and FI, including new technology, impact on the skin, and quality of life in patients with FI and an ostomy.
My article reviews the CMS Tag F 315 on urinary incontinence and catheters. Although it has been 18 months since its release, I continue to lecture to long-term care staff and providers who have yet to read these regulations and understand their implications. Changes to the regulations include a revision to the definition of incontinence, which now is defined as any wetness on the skin (in the past, most facility staff considered incontinence to be a complete void). The key to incontinence care is assessment of residents with UI and those at risk for developing incontinence. Once the assessment has been completed, the facility will be able to diagnose the type of incontinence and subsequently develop a care plan that can include several options such as behavioral programs (bladder retraining, pelvic floor muscle rehabilitation, prompted and scheduled voiding, drug therapy), intermittent catheterization, and use of pessaries and absorbent products. In addition to information on urinary incontinence, indwelling urinary catheters, and urinary tract infections (UTIs), this article provides information on transient and chronic UI, signs and symptoms of UTIs seen in residents with and without an indwelling catheters, and a best practice model for preventing UTIs.
Dr. Beitz discusses the etiologies, pathophysiology, and patient and organizational consequences of FI related to diarrhea, emphasizing management options that include fecal devices. She reviews the current approaches to managing liquid stool, which include containing or draining the liquid stool and drug therapy. Relevant devices currently are in use in most acute care settings. Nurses may not be aware of the current technology (fecal collectors, tubes, and bowel management systems) that is available.6
Most incontinence specialists believe that diarrhea or FI poses an even greater threat to skin integrity than UI, most likely due to digestive acids and enzymes in the feces that irritate and erode the epidermis.7 Evidence-based research to support this commonly held belief is scant. Dr. Bliss presents research on the occurrence and severity of skin damage in nursing home residents with FI, including the efficacy of four care regimens. Her large multisite study involved prevention of incontinence-associated dermatitis in nursing home residents as a primary outcome and detailed characteristics of incontinence-associated dermatitis, especially fecal incontinence. Dr. Bliss and her colleagues found that incontinence-associated dermatitis can be controlled with close monitoring and a defined skin care regimen; the “BIG” poster is a good way for staff to remember the perineal area requires continence care.
Dr. Colquhoun et al examine quality of life (QOL) of patients with FI who undergo an ostomy. The authors compare the results of currently available QOL questionnaires – the first attempt to develop an objective scoring tool to measure stoma function. The authors note subtle differences in the frequency of emptying and changing stoma appliances between ileostomy and colostomy patients, with the former group emptying their stomas more frequently and the latter changing their appliances more frequently. The authors hypothesize that the differences in the nature of the effluent produced by these two different types of ostomies likely affects patients and their “emptying” patterns differently. Problems with the current questionnaires are presented, indicating a need for further research in this area.
While botulinum toxin is widely used for cosmetic purposes, the real growth is in its application in urology as a treatment option for neurogenic and non-neurogenic overactive bladder (OAB), detrusor sphincter dyssynergia, interstitial cystitis, urinary retention, and prostate disorders. In “Notes on Practice,” Dr. Moy et al discuss the current use of botulinum injections in the bladder for refractory OAB, offering patients who have despaired of ever seeing symptom relief another option. I spoke with the woman detailed in the case study, who would say this treatment, “gave me my life back.”
I hope you find these articles informative and interesting. I am grateful to the editors of OWM for continuing to devote an entire issue to incontinence, a subject that hopefully will cease to be “taboo.”
1. State Operations Manual, Appendix PP – Guidance to Surveyors for Long Term Care Facilities, Center for Medicare and Medicaid Services, Tag F315, §483.25(d) Urinary Incontinence, (Rev.8, Issued: 06-28-05, Effective: 06-28-05, Implementation: 06-28-05. Available at: http://cms.hhs.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf::166-203. Accessed April 1, 2006.
2. Madoff RD, Parker SC, Varma MG, Lowry AC. Faecal incontinence in adults. Lancet. 2004;364:621-632.
3. Goode PS, Burgio KL, Halli AD, Jones RW, et al. Prevalence and correlates of fecal incontinence in community-dwelling older adults. JAGS. 2005;53:629-635.
4. Miner PB. Economic and personal impact of fecal and urinary incontinence. Gastroenterology. 2004;126:S8-S13.
5. Fonda D, Newman DK. Tackling the stigma of incontinence – promoting continence worldwide. In: Cardozo L, Staskin D (eds). Textbook of Female Urology and Urogynecology, 2nd ed. UK: Isis Medical Media, LTD;2006:75-80.
6. Newman DK, Fader M, Bliss DZ. Managing incontinence using technology, devices and products. Nurs Res. 2004;53(6 suppl):S42-S48.
7. Newman DK, Preston AK, Salazar S, Sarshik S. Moisture control, urinary and fecal incontinence and perineal skin management. In: Krasner DL, Rodeheaver G, Kane D (eds). Chronic Wound Care: A Clinical Source Book for Healthcare Professionals, 4th ed. Malvern, Pa: HMP Communications: In Press.
