INSTIGATING TREATMENT OPTIONS  

Both bladder and bowel function can be improved after undertaking a thorough initial continence assessment and identifying what type of continence problem the individual presents with (Booth, 2013). Healthcare professionals need to understand the different treatment options available to improve these symptoms. Information gained from assessment will be able to guide selection of appropriate treatment (Herbert, 2019), which ranges from simple lifestyle changes to more complex introduction of medications or pelvic floor rehabilitation. Before instigating any form of treatment, options should be fully discussed with the individual in a format they can understand, so that they can make an informed decision about progression. Indeed, working together towards a focused personal outcome will improve concordance with treatments and quality of life for individuals (Goodman et al, 2013).  

While some treatments options overlap and are suitable for both bladder and bowel problems, others are specific to either bladder or bowel, e.g. medication, and are presented as separate sections within this article. However, healthcare professionals should always be aware that some treatments options can cause and influence other types of continence issues, e.g. medication used to treat bladder urgency symptoms may cause constipation, which would need to be addressed.  

LIFESTYLE INTERVENTIONS  

Lifestyle interventions that can be offered as treatment options for individuals with both bladder and/or bowel problems may include (Herbert, 2019; Burkhard et al, 2020):  

• Fluid/dietary advice — amount and type  
• Weight loss  
• Smoking cessation  
• Physical activity/exercise  
• Toilet programmes/ prompted toileting  
• Use of correct sitting positions  
• Use of natural reflexes, i.e. gastric colic reflex.  

Fluid advice  

The general consensus is that an average healthy adult needs a daily fluid intake of approximately 1.5 litres in 24 hours to replace natural loss (Yates, 2016). However, this will vary and may depend on several factors, including illness and disease, age, weight, activity level, as well as external factors such as hot weather. Maintaining an appropriate fluid intake is vital for individuals who have bladder or bowel problems, as low fluid intake may contribute to constipation and dehydration, which may lead to bladder urgency and frequency, while increased fluid can increase voiding problems (Gilbert, 2006). The best form of fluid to advise is water, but some diluted squash or decaffeinated drinks can be alternatives (www.nhs.uk/live-well/eat-well/water-drinks-nutrition/).  

However, healthcare professionals should be aware of fluids that individuals with bladder/bowel issues should avoid. It is usual to advise people to decrease caffeine intake, if possible, as experts agree that it may have a stimulant effect on the bladder and exacerbate urgency, frequency and nocturnal voiding (Burkhard et al, 2020). It is mainly found in coffee, tea, drinking chocolate, cola and other carbonated drinks. It acts like a mild diuretic and can increase urine production if consumed in quantities exceeding 240mgs per day (Gilbert, 2006; Dumoulin et al, 2017; Herbert, 2019). This equates to two to three cups of coffee, six cups of tea, or five to six cans of soft drinks (Dumoulin et al, 2017; Herbert, 2019). Caffeine is not known to stimulate the gut, but it may increase water content of the stool to make it loose.  

Coffee has a stimulating effect on the bowel whether decaffeinated or not. Thus, it can assist individuals with constipation, but can cause loose stools and urgency in individuals with faecal incontinence and so should be avoided (Gilbert, 2006). While healthcare professionals should advise individuals to drink alcohol within the recommended limits, Dumoulin et al (2017) found no association with urinary incontinence and alcohol consumption. However, Gilbert (2006) states that it may have some diuretic effect and beer may have some laxative effect. Other fluids, such as fruit juices and herbal teas, can also have an impact on bladder or bowel continence (www.nhs.uk/live-well/eat-well/water-drinks-nutrition/) (Table 1). 

Dietary advice  

Individuals who suffer from bowel problems should be advised about diet and eating modifications. Those with constipation should eat high fibre foods, while those with faecal incontinence should avoid such foods, caffeine and artificial sweeteners (NHS Choices, 2018). Other conditions, such as lactose, wheat or barley intolerance, should also be ruled out before any treatment. Some individuals may require referral to a dietician for specialist advice, e.g. a low fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) diet (Herbert, 2019; www.theibsnetwork.org/diet/fodmaps). Probiotics and prebiotics may improve the balance of bacteria within the bowel and eating small regular meals rather than one large might assist with bowel dysfunction (Royal College of Nursing [RCN], 2019). 
 

Weight loss  

Weight loss to improve urinary symptoms has been recommended by the International Consultation on Incontinence (ICI) (Dumoulin et al, 2017), especially as a non-surgical intervention for overweight/obese women. This is also supported by the National Institute for Health and Care Excellence (NICE, 2019), which recommends that women with urinary incontinence or overactive bladder who have a body mass index (BMI) greater than 30 should lose weight. While there is no similar guidance for men, Burkhard et al (2020) state that all individuals who are overweight/obese who suffer from urinary incontinence should be encouraged to lose weight.  
 

Smoking  

There has been no conclusive data to show that smoking cessation reduces incontinence (Dumoulin et al, 2017), but due to the adverse effects of smoking on general health, healthcare professionals should provide strategies on smoking cessation (Burkhard et al, 2020). 
 

Physical activity/exercise  

There is little evidence that general moderate exercise decreases incidence of urinary incontinence. Strenuous exercise can though aggravate symptoms (Herbert, 2019).  
 

Toilet programmes/prompted toileting  

Burkhard et al (2020) recommend that toileting programmes may assist individuals with cognitive impairment, e.g. patients with dementia. If possible, find out about previous routines or habits, i.e. frequency of bowel movements, and look for any non-verbal signs that the individual may wish to use the toilet, e.g. fidgeting, pacing, holding their stomach (Dementia UK, 2017). Some people respond to regular toileting, such as including a note in their bladder diary as to how frequently they void, e.g. three hourly, and pre-empting when they need to go, i.e. take them every two to three hours.  
 

Correct sitting position and use of natural reflexes  

Note how often a patient needs to defaecate and check if they are using the correct sitting position on the toilet, i.e. feet should be on the ground or elevated on a stool to ensure that knees are above the hips, and the patient is able to lean safely forward with the lower abdomen bulged, but avoiding straining (International Continence Society, 2015; RCN, 2019). It may be of benefit to use natural reflex systems, i.e. gastric colic reflex, which is initiated when food and/or drink is ingested and sets off movement of the upper and lower gastrointestinal tract. It can be used to assist patients’ bowel emptying techniques by suggesting that half an hour after a meal they sit on the toilet to encourage a natural pattern of defaecation (RCN, 2019). 

PELVIC FLOOR REHABILITATION AND BLADDER/BOWEL RETRAINING  

 

Pelvic floor exercises  

Pelvic floor exercises have been shown to be a stand-alone therapy for the treatment of urinary incontinence (Herbert, 2019). Individuals need education and a pelvic floor rehabilitation programme that has been tailored to their capabilities and needs (Yates, 2019). They should be informed that it can take more than three months before they notice any improvement and that perseverance with, and adherence to, the exercise programme will be paramount (NICE, 2019).  
It is vital that individuals understand:  

• Where the pelvic floor muscles are  
• How they work and what they do  
• What the programme will hopefully achieve.  

Individuals should be instructed to undertake pelvic floor exercises in three positions, namely lying, sitting and standing to improve function (Yates, 2019). As well as the basic exercises, they can also be informed of supporting exercises, such as the knack whereby individuals are taught to pre-contract the pelvic floor before standing, sneezing, etc (Yates, 2019). There are also techniques such as the 50% lift, tightening after urinating, or defaecating, and even during sexual intercourse.  

There are devices that can help this treatment, i.e. pelvic educators, pelvic cones, biofeedback and neuromuscular electrical stimulation. However, these should be recommended and supervised by a professional knowledgeable in the treatments of the pelvic floor (Dumoulin et al, 2017; Yates, 2019). 
 

Bladder/bowel retraining  

Known also as bladder drill, this programme consists of patient education, along with a scheduled voiding regimen with gradual adjusted voiding intervals (Herbert, 2019). It aims to:  

• Improve bladder urgency, frequency, time between voids  
• Increase bladder capacity  
• Reduce incontinence episodes (Herbert, 2019).  

It is recommended that the programme is continued for at least six weeks (Herbert ,2019; NICE, 2019). Within clinical practice, bladder retraining is combined with pelvic floor training for individuals to be able to contract their muscles to hold on for longer periods and potentially safely reach a toilet. If not successful, it can be considered in combination with medication.  

The theory behind the programme of holding on and contracting the pelvic floor is the same for faecal incontinence and training the anal muscles. 

PHARMACOLOGICAL INTERVENTIONS  

Bladder  

Pharmacological therapies should only be initiated following a trial of non-pharmacological management and can often be used as an add-on to these therapies. Table 2 lists the drugs used to manage urinary incontinence, with the most common group being anticholinergics/antimuscarinics. 

Anticholinergics/antimuscarinics can reduce the sensation of bladder urgency and reduce unwanted bladder contractions (Madhuvrata et al, 2012). But, as said, they should only be instigated after failure of conservative therapies, i.e. bladder retraining.  

Unfortunately, there are side-effects (Table 3), which sometimes make individuals non-compliant with taking as prescribed.  

Initially, patients should be started with a low dose to facilitate tolerance, then gradually increasing until optimal balance of efficacy and tolerability is reached.  

There is a growing concern about the use of antimuscarinics due to the association with declining cognitive function, especially in the elderly and over 65s (Herbert, 2019). An antimuscarinic burden scale (ABS) has been developed to assess an individual’s risk with regards to this type of medication (Toozs-Hobson and Robinson, 2019). If individuals have a high ABS (over three), there is now an alternative medication, mirabegron. The licensed dose is 50mgs daily, although it can be reduced to 25mgs daily in patients with renal or hepatic impairment (Toozs-Hobson and Robinson, 2019). 
 

Bowel  

Lifestyle interventions should be tried before prescribing medication. There are different types of medication for bowel disorders which work in various ways. It is vital that healthcare professionals understand the different types according to patient assessment, needs and symptoms. It is also important to consider the type of bowel dysfunction, choice of route, administration times, duration and treatment, interactions and expected outcomes, cautions, contraindications and side-effects, licensed usage, as well as local formularies (RCN, 2019).  
 

Anti-diarrhoeal medication  

This medication is used to slow down the activity of the bowel and is typically used in faecal incontinence. In the author’s clinical experience, loperamide is the most commonly used medication, which can be given as a regular treatment or as required. It should be introduced at a very low dose and increased until desired stool consistency is reached (within constraints of British National Formulary [BNF] prescribing unless directed by specialist/consultant).  
 

Laxatives  

There are four basic types of laxatives (Table 4) (NHS, 2019). It is difficult to know whether a particular laxative will work better than another, and so choice depends on the person, and whether they can tolerate certain types, i.e. bulk forming laxatives are not recommended for people with poor fluid intake, and certain stimulants can give cramping effects (see Table 4 for complications), so an alternative may need to be used. It is recommended that individuals (NHS, 2019):  

• Start with a bulk-forming laxative  
• Try using an osmotic laxative in addition to, or instead of, a bulk forming laxative if stools remain hard  
• Try taking a stimulant laxative in addition to a bulk forming laxative if stool is soft but difficult to pass. 

There are also a number of alternative laxatives that are less commonly used, including bowel cleansing solutions, peripheral opioid-receptor antagonists, linaclotide and prucalopride. 

Linaclotide  

Linaclotide is a guanylate cyclase-C receptor agonist that is licensed for the treatment of moderate-to-severe irritable bowel syndrome (IBS) associated with constipation. It increases intestinal fluid secretion and transit, and decreases visceral pain (NICE, 2013; RCN, 2019).  
 

Prucalopride  

Prucalopride is a selective serotonin 5HT4-receptor agonist with prokinetic properties. It is licensed for the treatment of chronic constipation in adults, when other laxatives have failed to provide an adequate response (RCN, 2019).  

Laxatives should only be used as recommended by a healthcare professional and usually, unless required for a specific bowel condition, not too often or for too long as they can cause diarrhoea, or the bowel can become blocked with hard stool (intestinal obstruction) and unbalanced salts and minerals (NHS, 2019; RCN, 2019; BNF, 2021). 
 

Rectal preparations  

These preparations may be used (RCN, 2019):  

• In an acute situation when immediate results are needed to relieve symptoms  
• When oral laxatives are insufficient, as stimulants often need to be regularly increased to get the same initial effect; they become ineffective with regards to the bowel becoming more tolerant; or individual may no longer be able to tolerate orally due to changes in condition or palatability of the medication  
• Before/after surgery  
• For chronic conditions when normal bowel emptying is disrupted  
• To create a timed bowel movement to prevent faecal incontinence.  

Suppositories  

These are a medicated solid formulation for insertion into the rectum. Once inserted, body temperature will dissolve the medication. They can be used in combination with oral laxatives.  
 

Enemas  

These are a liquid preparation introduced into the body via the rectum to produce a bowel movement. Onset of action usually takes between 15 and 30 minutes, and they may be required for:  

• Acute disimpaction of bowel  
• Bowel clearance before surgery/investigations  
• Treatments of bowel disorders, e.g. ulcerative colitis/Crohn’s disease.  

Contraindications include:  

• Intestinal obstruction  
• Anal/rectal region diseases, i.e. active inflammatory bowel diseases such as ulcerative colitis and Crohn’s disease, which can lead to excessive absorption of carbon dioxide.  

Large volume evacuant enemas may be considered in acute constipation situations and for use before investigations. Phosphate enemas should be used with caution, as they can cause local irritation and electrolyte disturbance, and they should be used carefully with (RCN, 2019):  

• Older people and those who are debilitated  
• Individuals with clinically significant renal impairment.  

Contraindications include:  

• Conditions associated with increased colonic absorption, gastrointestinal obstruction, and active inflammatory bowel disease.  

CONCLUSION  

Treatment options vary according to the type of continence problem presenting to the healthcare professional. Conservative therapies should always be instigated first before proceeding to other treatments. Simple interventions, such as fluid/diet advice, weight management, exercise and smoking advice can be helpful. Further interventions, such as pelvic floor rehabilitation and introducing appropriate medication, can improve patient outcomes without the need for more invasive treatments, i.e. surgery. Healthcare professionals who look after individuals with continence issues need to be aware of the range of conservative therapies available.