Managing Incontinence Effectively: The Collaborative Continence Program

Jennifer Skelly, RN, PhD, helped found and is the Director of the Collaborative Continence Program at St. Joseph's Healthcare in Hamilton, Ontario.

1 - Tell me about the Collaborative Continence Program.
2 - Are there special circumstances related to seniors?
3 - Do you find clients apprehensive?
4 - Do more women than men experience incontinence?
5 - How do you assess your clients, particularly seniors?
6 - What are some of the underlying problems that may cause incontinence?
7 - Are there special problems men face?
8 - Are Kegel exercises effective?

A lot of people are mortified at the thought of talking to someone about their condition. ... Usually they leave very relieved to have found someone who understands and with whom they can talk.

1. The program is just finishing its fifth year. To my knowledge, it is unique in Canada in that it is independently nurse directed. We get 80 percent of our referrals from family physicians and 20 percent self-referrals, but when we started it was the exact opposite. I think that's because doctors have now seen what we've been able to achieve with conservative types of treatment. We try very hard to avoid the use of medication or surgery. We use pelvic muscle exercise training, and changing the amount (or type) of fluid people are drinking. If there is a large caffeine intake, we really encourage them to switch to decaffeinated beverages. Sometimes it's a question of urinating routinely, before the urge occurs, and often that will be successful.

2. We particularly look at how well they are coping on their own, what their hand function is like (which would be a factor in their ability to undo clothing), and what mobility they have. We are also interested in how well the bowels are functioning because constipation contributes to at least 50 percent of the problem with many seniors. With Alzheimer's or dementia, individuals sometimes lose the ability to understand the subliminal cue that tells them they need to go to the toilet. Sometimes this also happens after a stroke. Sometimes they forget where the toilet is. With Alzheimer's disease, it becomes a case of the caregiver always providing that direction. For people who live on their own, a watch can be set to beep every two hours. That works very well in the early stages. But if memory is failing they may not remember what the beep is for.

3. There's a certain amount of fear, especially if they've already had some kind of testing. A lot of people are mortified at the thought of talking to someone about their condition. Many are in tears when they first talk about it, because it has been such a big frustration. Usually they leave very relieved to have found someone who understands and with whom they can talk.

4. Yes. An interesting ratio, reported by the Australian Continence Foundation, is that one in four women and one in ten men will have had a problem with incontinence in their lifetime. The more disability involved the more likely there will be a problem. Then too, a lot of younger women have a problem with leakage when they laugh, cough or sneeze. They assume that's normal, whereas pelvic muscle exercises will improve or get rid of it. We are working hard to make people aware that it's a treatable problem and more doctors are referring clients with onset symptoms.

5. With all clients we do an extensive history. We have them urinate to measure the amount of urine and check for urinary tract infection. Then we use an ultrasound to scan the bladder to make sure it is emptying properly. With women we examine the labia and put one finger into the vagina to check muscle tone. If there are larger problems that are beyond the scope of our practice, we refer them on to a urogynaecologist or a urologist.

6. Probably 20 percent of people with a problem also have an infection, and seniors often have no idea they have an infection because they don't have burning or discharge. Often the only symptom is the onset or an increase in incontinence. We use urine dipsticks to check for infection. The dipsticks also register glucose. If someone with diabetes is seeing me for urgency and night time frequency and they are showing high sugar during the day, getting them back on track with their diet often solves the night time problem.

7. We work with one urologist who refers clients to us before radical prostate surgery. This allows us the opportunity to teach Kegel exercises beforehand, to tell the client what it's going to be like when the catheter comes out, and prepare them for the fact that they may experience a little or a lot of incontinence at first. In fact, we saw a gentleman yesterday who first came in five weeks ago, had his surgery four weeks ago, and is now at least three months ahead of the people we don't see until three, six, or nine months after surgery.

8. Yes, but if they have not been taught properly, they don't work. We no longer recommend stopping and starting voiding as a method of locating the appropriate pelvic muscles, because voiding isn't just about muscle control. Now we teach people to tighten their rectum. It's a simple exercise to do, but you'd be amazed at the number of people who think it's about tightening their buttocks, or tightening up their abdomen, or doing pelvic tilts.

People who experience excessive bladder contractions may benefit from medications designed to reduce them. Excessive sphincter contractions can also be treated with medicine, as can an underactive bladder. Some prescription drugs have side effects which should be discussed with your doctor.