Continence Problems Research Articles

Neurophysiologische Diagnostik bei analer Inkontinenz und Obstipation

Neurophysiological tests are mostly ordered by neurologists, who are also the primary evaluators. In dysfunctions of the pelvic floor, the question is raised by a non-neurologist, who is called upon first to classify the results. This requires an interdisciplinary cooperation, which is rarely warranted at any time, and in any place. The tools available include myography, neurography and evoked potentials. The most common issues in neurocoloproctology are anal incontinence and constipation. EMG of the anal sphincters is the conclusive diagnostic method in this regard. Neurography of the pudendal nerve (PNTML) is merely playing a secondary role. Other measurements do not apply unless a specific problem is at stake. The EMG permits the qualitative and quantitative proof of a neurogenic lesion in the presence of fecal incontinence aside from the differentiation between spasticity, anismus and malcoordination. These diagnostic techniques should be offered and mastered by all major centers for continence problems and muscular failure of the pelvic floor.

Childhood continence issues

Before specialist help is enlisted and medication given to the child with continence problems, simple methods should be considered, writes Heather Welford argues

Gait disorder in older adults

In normal pressure hydrocephalus (NPH), there is enlargement of the brain's ventricular system due to an excess of cerebrospinal fluid. The triad of symptoms in NPH are gait disorder, cognitive impairment, and urinary continence problems. NPs need to consider the possibility of NPH in older adults with a hypokinetic gait.

Musical approach calms children with continence problems

Musical approach calms children with continence problems

Continence problems in the house-bound patient: causes and treatment

This article provides an overview of faecal continence with a focus on the house-bound patient. To understand incontinence it is essential to understand how continence is achieved. Causes of faecal incontinence are discussed, including anal sphincter damage. Finally the nursing, medical and surgical treatment options are explored. This includes medication, biofeedback and the formation of a colostomy.

Developing and evaluating assistive technology for continence problems

Developing and evaluating assistive technology for continence problems

Conservative management of faecal incontinence in adults

While faecal incontinence is a common problem, many people may be embarrassed to admit having the condition. An understanding of the various factors that contribute to faecal incontinence can increase nurses' awareness of potential continence problems. Nurses can assess patients for faecal incontinence, provide valuable information and implement a range of management strategies to support patients and improve their quality of life. This article explains the reasons for incontinence, outlines comprehensive patient assessment and discusses the various treatment options to help patients overcome or manage the problem. The author describes the role of continence advisers and clinical nurse specialists who can offer additional expertise.

Multidisciplinary care needs in an Australian tertiary teaching hospital

The ageing of the Australian population is placing increasing demand on the nation's healthcare system. This study set out to describe the level of need for multidisciplinary care in an Australian tertiary hospital setting. A cross-sectional audit by case note review of all patients on acute medical and surgical wards in an Australian tertiary hospital. The primary outcome was an identified need for multidisciplinary assessment and intervention. A total of 60% of the 295 inpatients audited required multidisciplinary care. Of those who were admitted to geriatric and rehabilitation units, 84% required multidisciplinary care. Patients in acute medical and surgical units also had substantial multidisciplinary care needs. Age was a significant influence with 79% of those aged 86 and above having multidisciplinary care needs, whilst only 38% of those aged 55 or less required multidisciplinary care. Difficulties with mobility, need for assistance with self-care, and continence problems were associated with higher requirement for multidisciplinary care. In the hospital population, significant multidisciplinary care needs exist. These needs are not limited to inpatients that are elderly or admitted to geriatric or rehabilitation units. This has implications for planning, funding, provision of health care resources, and training of medical and allied health staff.

The effective management of catheter-related UTIs

The majority of patients currently residing in Britain's hospitals are older people, many of whom have continence problems that may result in catheterization. Older people are also particularly vulnerable to infection and the consequences of sub-optimal care. Urinary tract infection is the most common health-care-acquired infection and most urinary tract infections are a result of urinary catheterization. This extended case study illustrates how ritualistic catheter care can increase the risks of an older person developing an infection as well as a host of other problems as a result of that infection. It then examines how evidence-based catheter care can reduce the risk of infection and adverse events as well as providing successful patient outcomes.

A new source of support for continence problems

People who experience continence problems can often find it difficult to access support, especially as there is a dearth of publicity about the issue and many people who have an problem with continence feel stigmatized. Even when people do seek help, or experience difficulties after inpatient care, such as following childbirth, it can be difficult to access advice and appropriate products.

The Female Genital Mutilation Act 2003: an overview for district nurses

Female genital mutilation (FGM) includes procedures that intentionally alter or injure female genital organs for non-medical reasons. An estimated 100 to 140 million girls and women worldwide are currently living with the consequences of FGM with some three million girls at risk in Africa every year. The procedure has no health benefits and can cause severe bleeding and continence problems, and later, potential childbirth complications and newborn deaths. FGM is internationally recognized as a violation of one's human rights (World Health Organisation, 2008). In the UK it is a procedure outlawed by the Female Genital Mutilation Act 2003.

Increased late urinary toxicity with whole pelvic radiotherapy after prostatectomy

Background. Radiotherapy aimed at prostatic bed (PBRT) can prevent recurrence or reestablish remission in prostate cancer patients primarily treated with prostatectomy. In selected patients results may be improved with the additional irradiation of pelvic nodes (WPRT). Patients and methods. The objective of the study was to evaluate late toxicity of postoperative radiotherapy in 43 patients – 21/43 treated with WPRT. Dysuria, haematuria, nocturia, continence and obstructive urination problems as well as urgency, continence, frequency, pain and bleeding of defecations were prospectively registered and converted to a modified Radiation Therapy Oncology Group (RTOG) – late effects normal tissue (LENT) scoring system. Median tumour dose (TD) for PBRT was 64.8 (59.4-70.0) Gy and for WPRT 50.4 (48.0-56.0) Gy. Results. More important than the deterioration of intestinal function (worsening for 1 grade in 54% and 2 grades in 5% of patients) was the deterioration of urinary function (worsening for 1 grade in 33% and 2 grades in 26% of patients). This appeared to be more frequent in patients with WPRT than PBRT (67% vs. 50% of patients) especially in conjunction with WPRT TD >52 Gy (deterioration in 71% of patients). Conclusions. Although several factors may influence increased urinary toxicity after WPRT, it seems reasonable to lower the urinary bladder dose as it possible with novel radiation techniques.

Die Situation von PflegeheimbewohnerInnen mit Kontinenzproblemen: eine Studie in 2 deutschen Pflegeheimen

To describe the situation of residents with continence problems (CP) in two German nursing homes. Medical and nursing records of all residents were reviewed and categorised according to a standardised protocol. Structured interviews were performed with the responsible nursing staff of each resident. Qualitative methods like focus groups and participating observations were used to collect further information. In the investigated nursing homes 177 residents with and 70 without CP were identified (81.5% women; mean age 83.7 years). For these 247 residents 57 physicians and 116 nurses or nurses-aides were in charge. 71% of female and 76% of male residents had at least one CP. The three most common CP among residents were combined urinary and faecal incontinence (32%), urinary incontinence (21%), and urinary catheters (17%). Residents with CP were significantly more dependent in functional abilities like toileting, dressing or cognitive function than those without CP (P<0.01). In a high proportion of residents with CP physicians (64%) were not consulted nor were relatives (86%) involved in continence related activities. Nursing home residents are commonly affected by continence problems which are associated with functional dependency and relevant co-morbidity. The public and expert debate on continence problems of nursing home residents has to be promoted to achieve long-term changes.

Long-term bowel function and quality of life in children with Hirschsprung's disease

Background/PurposeLittle is known about the quality of life (QOL) of children with Hirschsprung's disease (HD) as they grow older. The purpose of this study was to measure the QOL and bowel function of these children as they mature. MethodsAll children who were surgically treated for HD at British Columbia Children's Hospital, Vancouver, British Columbia, Canada between 1986 and 2003 were invited to participate. Each family was sent 3 previously validated questionnaires exploring current QOL and bowel function. ResultsFifty-one families participated (49%), with children between the ages of 3 and 21 years. Fecal continence improved significantly with age (P = .04) and was the strongest predictor of QOL scores of all variables in our study. There was no statistically significant difference in QOL scores between children with HD and healthy children, although a clinically relevant impairment in QOL may be present, especially in psychosocial scores. ConclusionsFecal continence is an important predictor of overall QOL in children surgically treated for HD. Although continence tends to improve with age, a number of older children still have ongoing continence problems, and they seem to be a group at risk for impaired QOL. Our study indicates that interventions for children with incontinence may offer gains in QOL as well as bowel function.

Continence promotion for older hospital patients following surgery for fractured neck of femur: Pilot of a randomized controlled trial

Evidence suggests that bladder control problems develop or worsen as a result of fractured neck of femur (#NOF) and its subsequent management. The primary aim of this study was to reduce the prevalence and severity of post surgery continence problems among patients, aged from 60-years, undergoing surgery for #NOF, using a best practice "case-management model" multifactorial intervention. Eligible consenting patients admitted with #NOF were randomized to intervention or control group. Self-report questionnaires compared pre-surgery, post surgery, and follow-up continence status between groups. This pilot randomized controlled trial, which included 45 eligible patients aged 60 to 93-years, found no evidence that the intervention was effective in reducing prevalence of post-surgery incontinence in this acute setting. Staff surveys highlighted the need for open communication between the research team and hospital staff. Unclear results were attributed to the small sample size. A central outcome was evidence that intervention to improve continence management for older people post-surgery is imperative. Focused assessment and treatment for those most at risk of incontinence after #NOF would be more acceptable to staff and a more efficient use of resources. A simple screening tool would ensure that those most at risk are detected, and targeted for care.

Long-term Results of Intersphincteric Resection for Low Rectal Cancer

In the treatment of very low rectal cancer, a distal resection margin of more than 1 cm can be obtained by partial internal sphincteric resection, allowing a sphincter preserving surgery. Thus, intersphincteric resection (ISR) has been proposed as an alternative to abdominoperineal resection for selected low rectal cancer. The aim of our study was to assess the morbidity, mortality, and the long-term oncologic and functional results of ISR. Charts of patients who had ISR between 1992 and 2004 were reviewed. Cancer-related survival and locoregional recurrence rates were calculated using the Kaplan-Meier method. Functional outcome was assessed by using a standardized gastrointestinal functional questionnaire. Incontinence was assessed by the continence score of Wexner. Ninety patients (59 males, 31 females) with a tumor at a median distance of 35 mm (range, 22-52) from the anal verge had an ISR. Thirty-seven patients (41%) had preoperative radiotherapy. Histologically complete remission after neoadjuvant radiotherapy (ypT0) was observed in 7 patients (8%), 12 patients (13%) were pT1, 35 patients (39%) pT2, 32 patients (36%) pT3, and 4 patients (4%) pT4. Five patients (5.5%) had synchronous liver metastases. R0 resection was obtained in 85 patients (94.4%). The median distal resection margin on the fixed specimen was 12 mm (range, 5-35) and was positive in 1 case. The circumferential margin was positive (< or =1 mm) in 4 patients (4.4%). There was no mortality. Complication rate was 18.8%: anastomotic leakage occurred in 8 patients (8.8%) and 1 patient had an anovaginal fistula. Five patients (5.6%) underwent secondary abdominoperineal resection: 1 for positive distal margin, 1 for colonic J-pouch necrosis, and 3 for local recurrence. ONCOLOGIC RESULTS: After a median follow-up of 56.2 months (range, 13.3-168.4), local, distant, and combined recurrence occurred in 6 (6.6%), 8 (8.8%), and 2 patients, respectively. Thirteen patients (14.4%) died of cancer recurrence. Five-year overall and disease-free survival was 82% (80-97) and 75% (64-86), respectively. In univariate analysis, overall survival was significantly influenced by pTNM stage and T stage (pT 1-2 vs. 3-4: P = 0.008 and stage I-II vs. III-IV: P = 0.03). In multivariate analysis, we did not find any impact on local recurrence-free survival for the investigated prognostic variables. For a total of 83 patients the mean stool frequency was 2.3 +/- 1.3 per 24 hours. Forty-one percent of patients had stool fragmentation, one-third nocturnal defecation, 19% fecal urgency, and 36% followed low fiber diet. Thirty-four patients (41%) were fully continent, 29 patients (35%) had minor continence problems, and 20 patients (24%) were incontinent. After adjustment for age, gender, tumor level, and pTNM stage, preoperative radiotherapy was the only factor associated with a risk of fecal incontinence [OR (IC 95%) = 3.1 (1.0-9.0), P = 0.04]. In selected patients, ISR is a safe operation with good oncologic results. It achieves good functional results in 76% of patients. Functional results are significantly altered by preoperative radiotherapy.

Care of continence during the terminal phase of illness

This article will explore the issue of continence care during the terminal phase of life. This period is often referred to as ‘the end of life’ or ‘the last 48 hours’. Patients are thought to be in the dying phase of their illness when they only have hours or days left to live (referred to as the ‘terminal phase’ in this article). Continence care is complex during the terminal phase as it can have a significant impact on the dignity of patients and adds to their physical and emotional burden. The care given is both intimate and embarrassing, often involving invasive procedures, at a time when patients may be unable to make choices. Therefore, discussion of possible continence problems should be broached sensitively with patients when they are still able to make decisions on their preference for continence care. However, continence problems during the terminal phase are unpredictable, leaving healthcare professionals unprepared on how to best treat the symptoms of urinary and bowel problems. This article explores the available interventions and their appropriateness to the terminal phase. Conflicts of interest: none

Our Experience with Transanal Endorectal Pull-Through in Hirschsprung's Disease

The aim of the study was to evaluate the functional results, complications, the problems caused, and the outcomes of the transanal endorectal pull-through (TEPT) operation in Hirschsprung's disease. The 22 patients who were operated for Hirschsprung's disease with TEPT between November 2003 and September 2006 were reviewed retrospectively. The patients were evaluated for age, gender, operational findings, duration of hospitalization and functional outcomes after the operation. A total of 22 patients, sixteen males (72.7 %) and 6 females (27.3 %) aged 23 days to 11 years (mean 19.3 +/- 6.9 months), were operated using TEPT over a 34-month period. The mean length of the resected aganglionic segment was 23 +/- 2.4 cm; the shortest segment was 7 cm and the longest 40 cm. The postoperative hospital stay was 3 - 10 days, oral feeding was started at 1 - 4 days, the first bowel movement was at 1 - 7 days and the number of daily movements for patients in whom the colostomy was closed was 2 - 5. The mean postoperative follow-up period was 18 +/- 2.4 months (1 - 33 months). Two patients (9 %) were hospitalized once for enterocolitis. One patient had a constipation problem that resolved with medical treatment. One patient needed colostomy for anastomosis leakage on the 5th postoperative day, followed by a redo pull-through using a posterior sagittal approach. None of the patients had a continence problem. No urethral damage was observed and there were no abscesses at the muscular cuff. We observed that mucosal dissection was more difficult in the rectal biopsy area. Although only recently accepted, TEPT has quickly found a place in clinical practice as it is based on an operational technique whose results are well identified and accepted and with which there is extensive experience. It seems that TEPT has the advantages of having no additional problems compared to the classical techniques with respect to complications and functional outcomes while providing better patient comfort and cosmetic outcomes. We conclude that TEPT may be preferred in appropriate cases and will evolve to become a more practical and effective technique.

Creating a continent care environment for patients

Care assistants working in hospitals often care for people who are incontinent of urine. Incontinence affects 2–6 million adults in the UK and some people develop continence problems for the first time when admitted to hospital. This article explains how the urinary system functions and how ageing, illness, hospital treatment and care practices can lead to incontinence developing. It also offers advice to enable care assistants to enable people to maintain continence.

Managing a common dermatological problem: incontinence dermatitis

Incontinence dermatitis is an under-recognized and under-researched problem that mostly affects older people who have continence problems. Nurses who are aware of the risk factors can provide care that reduces the risk of this distressing problem. If incontinence dermatitis occurs, evidence-based care can be used to treat the person and reduce the risks of further complications.