E-21 Bowels and Bladder
Trouble-free control over excretory functions is taken for granted. It is a topic many people are reluctant to discuss. Lack of control is associated with stigma, not only when someone is incontinent. It is also related to sexual dysfunction because of the close anatomical relationships and the additional concerns arising from the fear and consequences of losing control. Disturbed control includes constipation and urinary retention. Problems with bowel and bladder function are common; they are not only secondary to neurological damage. Indeed, functional bowel and bladder dysfunction is well-known and quite frequent. In most cases, many factors contribute to dysfunction, and many consequences arise. Managing these problems well requires knowledge of everything from anatomy to sociology.
Table of Contents
Bowels and bladder: the competency.
The competency is that the rehabilitation expert is “able to assess, provide advice about, and manage bladder and bowel dysfunction.” While many patients have neurogenic causes and the approach will be similar, it is crucial that the expert can manage these problems, whatever the aetiology. More details about indicative behaviours, knowledge, and skills can be downloaded.
The stigma associated with excretory functions must not be forgotten or underestimated. People are reluctant to talk about them to anyone, professionals often avoid asking about them, and healthy people with no problems avoid direct reference, talking about “spending a penny”, “going to the bathroom”, or “visiting the loo.” Moreover, care workers who manage people with incontinence also feel stigmatised by their work. The pain and distress caused by incontinence or frequency are considerable.
Problems with or arising from limited control over excretion are common. Neurogenic dysfunction is the most well-recognised type, and pelvic floor problems are another direct cause, but many people do not have a clear-cut single reason. The influence of a person’s emotional state and other psychological factors must not be underestimated. For example, almost everyone develops dysfunction when anxious; many people involved in the D-Day landings were incontinent of urine or faeces as they approached their destination.
Unsurprisingly, problems with excretion are referred to hospital specialists, such as gynaecological surgeons, urologists, gastrointestinal surgeons, gastroenterologists, and geriatricians. Each will have an area of interest and may offer a specific direct treatment, such as an operation to repair damage to the pelvic floor. However, specific medical or surgical treatments have only a minor impact on many people. Consequently, generic incontinence services are found in most areas, and they will take a pragmatic approach.
Patients with incontinence are found in most areas of rehabilitation. The holistic rehabilitation approach is well-placed to help because it is familiar with complex problems with no unique reversible cause and no specific treatment.
No medical speciality focuses on incontinence across all causes; it has a low status despite its frequency and social impact, and research into managing it has a low priority. Many patients’ problems cannot be resolved, and for many people, it causes continuing distress because management is not satisfactory.
NHS guidance on bowels and bladder dysfunction.
The NHS has published significant guidance to improve services, many published by the National Institute of Health and Care Excellence (NICE). This guidance is a good starting point. They vary in their focus, some being broad and some focused on a specific intervention or cause.
Neurological diseases are commonly associated with incontinence. The disorders include spinal cord damage, focal brain damage, and general cerebral dysfunction, such as dementia. These conditions are covered by Urinary incontinence in neurological disease: assessment and management, Clinical Guideline 148, published in 2012 and reviewed in 2019. The website includes additional valuable resources, such as audit and service standards; it also details the evidence used, which will give anyone a good start. It covers all aspects from initial assessment to treatment and service audit.
Women frequently experience incontinence associated with pelvic floor dysfunction, and several NICE documents cover these problems. Urinary incontinence and pelvic organ prolapse in women: management, National Guideline 123 published in 2019, addresses urinary incontinence and, additionally, pelvic organ prolapse. This includes surgical treatments and vaginal mesh surgery and its sequelae. Pelvic floor dysfunction: prevention and non-surgical management. NG210 discusses non-surgical management in all women aged 12 years or over.
Men also have urinary tract symptoms and Lower urinary tract symptoms in men: management, clinical guideline CG97 covers the assessment and the use of several treatments.
Faecal incontinence and constipation are significant problems for many people with marked disabilities. Some issues arise from the underlying disease, but the secondary consequences of immobility are also a common cause of difficulties. An old clinical guideline published in 2007 covers Faecal incontinence in adults: management (CG49). There have been significant developments since.
NICE covers two stimulation techniques: sacral nerve stimulation for faecal incontinence (IPG99) and percutaneous tibial nerve stimulation for faecal incontinence (IPG395).
Another new approach is transanal irrigation. NICE updated their guidance on Peristeen Plus in medical technologies guidance, MTG36, Peristeen Plus transanal irrigation system for managing bowel dysfunction. NICE concluded that Peristeen Plus “can reduce the severity of constipation and incontinence, improve quality of life and promote dignity and independence.”
NICE discusses how this treatment should be introduced in Adopting Transanal irrigation as a treatment option for people with bowel problems at St Helens and Knowsley Teaching Hospitals NHS Trust. This is interesting because it reports on a project introducing Peristeen (transanal irrigation) as a treatment for constipation, and its evaluation strongly supports its use. The documents and website will help other services obtain resources to develop their services.
Knowledge and skills.
The best way to learn about managing bowel and bladder problems is to spend time with an incontinence service that sees people with various issues with many different causes and in multiple settings. Like most rehabilitation, efficient and effective management requires a systematic and holistic assessment and formulation followed by trials of various interventions. There is rarely any straightforward, evidence-based best treatment. Each locality and service will have strong points and resources, and other options may not be readily available.
The stigma associated with any difficulties with control over bowel or bladder function can only be overcome by excellent and sensitive communication. Having high-level knowledge about exciting techniques and available expert resources can only help if the patient’s problem is identified and they feel sufficiently respected and understood to try treatments. Furthermore, most treatments are low-tech, such as pelvic floor muscle exercises, and people need education and persuasion to try them.
for the clinician, so it is often not mentioned. For most patients, an easy, effective treatment is rarely available to resolve the problem entirely. Clinicians know that excretory dysfunction is a challenge. However, a holistic approach coupled with an attention to detail can often improve a person’s life remarkably. As with chronic non-malignant pain, one must focus on achieving a better quality of life and not on achieving a cure. Thus, a combination of good communication, a holistic person-centred approach, ensuring that goals concern quality of life and not cure of the problem, and a practical trial-and-error approach will benefit patients and, hopefully, lead to professional satisfaction.