A Proactive Approach to Bowel & Bladder Management in Adults

• Understand the subtypes of fecal incontinence experienced (i.e., passive fecal incontinence, urge fecal incontinence or functional fecal incontinence).
• Identify a list of risk factors for fecal incontinence
• Obtain history on the following
  
  • Daily bowel habits—including frequency and stool consistency, as well as the onset, duration and severity of symptoms—to understand the type of fecal incontinence.
  • Information regarding the timing of fecal incontinence (e.g., post-defecation or during the night) to evaluate if fecal incontinence is associated with a bowel movement.
  • Dietary history, to rule out possible underlying causes.
  • Medications, to evaluate the effect on fecal incontinence.
  • Co-morbid conditions, to determine possible underlying causes.
  • Obstetric history, to rule out fecal incontinence associated with the use of forceps, birth weight greater than 4 kg or a fourth-degree tear. 52
  • Previous surgeries (e.g., anal fissure surgery or fistula surgery), pelvic radiation or other pelvic floor problems (e.g., urinary incontinence or pelvic organ prolapse) that may contribute to fecal incontinence.
  • Impact of fecal incontinence on quality of life

To view practice notes from expert panel click here

Strong Recommendation

A strong recommendation reflects the expert panel’s confidence that the desirable effects of an intervention outweigh its undesirable effects (strong recommendation for an intervention) or that the undesirable effects of an intervention outweigh its desirable effects (strong recommendation against an intervention). A strong recommendation implies that the majority of persons will be best served by the recommended action.

Conditional Recommendation

A conditional recommendation reflects the expert panel’s confidence that the desirable effects probably outweigh the undesirable effects (conditional recommendation for an intervention) or undesirable effects probably outweigh desirable effects (conditional recommendation against an intervention), but some uncertainty exists”. A conditional recommendation implies that not all persons will be best served by the recommended action: “there is a need for more careful consideration of personal circumstances, preferences, and values”.

• The involuntary loss of liquid or solid stools. Fecal incontinence can be caused by physiological, mechanical and medical factors, including (but not limited to) constipation, muscle injury or muscular weakness, nerve damage, neurologic diseases, loss of stretch in the rectum, hemorrhoids or rectal prolapse.
• There are different subtypes of fecal incontinence:
  
  •  Passive fecal incontinence: The “involuntary leakage of feces without forewarning. A small amount of soiling and seepage between the buttocks or on a small pad or underwear are symptoms of minor passive fecal incontinence. Passive fecal incontinence is frequently related to internal anal sphincter dysfunction, while urge fecal incontinence is often associated with external anal sphincter dysfunction”.
  • Urge fecal incontinence: The inability to defer defecation once the urge is perceived for long enough to reach a toilet. However, as distances to a toilet will vary, this is an inconsistent and uncontrolled condition.
  • Functional fecal incontinence: The involuntary leakage of feces due to limitations in mobility, manipulating clothing, or toileting ability or delayed assistance with toileting.

• The involuntary leakage of urine caused by physiological, mechanical and medical factors, including (but not limited to): weak pelvic muscles, diabetes, certain medications, constipation and bladder infection.
• The most common types of urinary incontinence (stress incontinence, urgency incontinence, mixed incontinence and functional incontinence) are described below. There are additional types of incontinence. Further, clinical indications that fall outside of the common types of incontinence warrant referral to a continence specialist for further assessment and management.
  
  • Stress incontinence: The involuntary loss of urine due to a sudden increase in intra-abdominal pressure via physical exertion, including coughing, sneezing, laughing, rising from a chair, lifting items or exercise.
  • Urgency incontinence: The involuntary loss of urine that occurs when there is a sudden, compelling urge to urinate and the bladder contracts and empties in an involuntary fashion.
  • Mixed incontinence: The involuntary loss of urine associated with urgency and physical exertion (e.g., coughing or sneezing).
  • Functional incontinence: A type of urinary incontinence that occurs in instances where someone has normal urine control but may have trouble getting to the bathroom in time because they live with conditions that make it difficult for them to move around (such as decreased mobility). It may also be referred to as “disability incontinence”.

Sample Voiding Record

This chart allows the person to record when and the amount of urine they pass in the toilet, when and how much they drink as well as record when they have a wet episode.

To view chart click here

• A comprehensive assessment would be conducted by a health provider who has the appropriate knowledge and skills pertaining to one’s functional abilities in performing PFMT, such as a nurse continence advisor (NCA) or a pelvic health physiotherapist

• PFMT program should comprise at least eight contractions, performed three times per day
• Do not use perineometry or pelvic floor electromyography as biofeedback as a routine part of PFMT
• Continue the exercise program if PFMT is beneficial.

• Low-intensity physical activity refers to light, non-strenuous and repetitive bodily movement, such as walking, low-impact aerobic exercise and light resistance training.
• Low-intensity physical activity should be individualized and appropriate to the person’s age, physical ability and associated health status.

An initial assessment of urinary incontinence can be guided by the following components:

1. Obtain a clinical history to accurately determine the type of urinary incontinence and the possible underlying causes.

2. Obtain a voiding record to evaluate the frequency of incontinence and voided volume.

3. Assess urinary urgency using validated questionnaires.

4. Use dipstick urinalysis as a screening tool to further assess glycosuria, hematuria, proteinuria and pyuria, in accordance with the policies and procedures of the local setting.

5. Measure post-void residual (PVR) volume within a few minutes of voiding, either by calculating bladder volume using a portable ultrasound scanner or by in and out catheterization (unless otherwise directed).

To view practice notes from expert panel click here.

• This BPG focuses on bladder and bowel management in adults (aged 18 years and older)
• The purpose of this BPG is to provide evidence-based recommendations for effective strategies to support adults who live with urinary incontinence, fecal incontinence and/or constipation that will improve quality of care and lead to positive health outcomes.