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Continence problems following a stroke

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VOL: 98, ISSUE: 17, PAGE NO: 50

Katherine Brittain, BSc, MA, is research associate, Centre for Health Services Research, University of Newcastle upon Tyne

Rehabilitation is a significant component in the management of patients with stroke and its focus is to reduce stroke-related disability. Addressing urinary incontinence is an important aspect of the rehabilitation process.

Rehabilitation is a significant component in the management of patients with stroke and its focus is to reduce stroke-related disability. Addressing urinary incontinence is an important aspect of the rehabilitation process.

Objective
The study aimed to assess and improve the quality of care for urinary incontinence on a ward for stroke rehabilitation.

Methods
This was a prospective study carried out by a registered nurse who followed the study subjects from admission to a stroke rehabilitation ward and monitored them for urinary incontinence during their stay. Urinary incontinence was assessed using clinical judgements, interviews with patients and their families.

Patients who had occasional accidents (defined as those who had accidents while waiting for a bedpan or commode) and patients who were only incontinent at night (due to drowsiness or waiting for assistance during the shift with the lowest nursing staff level) were not defined as being incontinent of urine in this study. Continence status was assessed at admission, at six weeks, at discharge and at six months. Functional independence measuring scores were taken.

Results
Thirty-seven patients were included in the study. The mean age of the sample was 61, and 68% were male. The mean stay of incontinent patients was 114 days compared with 91 days for the continent ones. Incontinence care on the ward included:

- Promoting continence by placing patients on a commode or offering them a urinal/bedpan every two to four hours;

- Provision of aids/appliances: 54% were given Fowley's condom catheters, 35% pants;

Sixty-one per cent of the sample had a urinary infection which was detected early and responded well to treatment; 22% had skin irritations due to the incontinence. Out of the 84% of patients who were discharged home, 25% were continent at discharge and 55% were continent at six months.

Discussion and conclusion
On admission 26% of the stroke survivors who were defined as incontinent were classified as being functionally incontinent. They were unable to get to or use the toilet due to poor mobility, difficulties in manipulating clothing and/or cognitive impairment. A further 20% were found to experience urge incontinence and 52% had a combination of the two. Their care was aimed at the prevention of complications and minimisation of interference with rehabilitation therapies. Intermittent catheterisation and treatment with anticholinergic medication were not practised.

Commentary
Research has shown that urinary incontinence is a prevalent complication following stroke and has been reported to be as high as 79% at the time of admission to hospital (Brittain et al, 1998). In the past research on stroke and incontinence has tended to focus on the predictive element of this symptom, as it has been shown to be associated with death and disability (Brittain et al, 1998).

Stroke outcome is shown to be better in patients who remain or become continent, and it is suggested that this symptom should be targeted as a goal of therapy in the stroke rehabilitation setting (Barer 1989). The study under review here has highlighted and recognised that urinary incontinence following stroke is an important area for improving quality of care in stroke rehabilitation.

The management of bladder and bowel problems is seen as an essential area of survivors' rehabilitation (Royal College of Physicians of London, 2000). Hospitals should have established assessment and management protocols for urinary incontinence, and continence services should cover both the hospital and the community to ensure continuity of care (Royal College of Physicians, 2000; Department of Health, 2000; Department of Health, 2001).

Hospital nurses dealing with urinary incontinence, including nurse specialists for stroke patients, should be adequately trained to carry out initial assessments and management of incontinence (Prophet, 1998; Department of Health, 2000; Royal College of Physicians, 2000). Nurses need to be able to review the survivors' symptoms, assess the hospital environment (for example, accessibility of toilet facilities), advise on fluid intake, implement bladder training and review medication (Department of Health, 2000). In the paper reviewed here, the authors need to be more explicit about the initial assessments that were carried out and the continence training undertaken by the research nurse.

Furthermore, although the authors have highlighted an important area for improving quality of care, the quality indicators they employed were limited. The promotion of continence through scheduled toileting is proposed as one of the management strategies for good practice (Department of Health, 2000). However, further strategies could also have been used. These include a review and adjustment of patients' fluid intake and a review of their medication.

As part of an established and valued model of continence service for stroke survivors, reviewing and prescribing medication is one of the most common interventions (Addison et al, 2001). This might have helped to overcome the night-time drowsiness experienced by the stroke survivors and therefore assisted in avoiding the 'occasional accidents' reported in this study.

In addition, stroke survivors who were incontinent because of the low level of night-time nursing staff or waiting for a bedpan or commode could be seen as indicators of a poor service. Patients should be able to expect that their personal hygiene needs are being met in a sensitive way (Department of Health, 2001). Therefore part of the nurse's role advocated in Good Practice in Continence Services (Department of Health, 2000) is to assess the patient's environment, especially the accessibility of toileting facilities. Pads and appliances should only be issued after an initial assessment has been carried out. All of these factors need to be incorporated into any service that aims to improve the quality of care for stroke survivors with incontinence.

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