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Your guide to which medications affect continence ... page 8

How to avoid urinary retention after childbirth ... page 12

Issue 21 Spring 2010

continence care

Looking after our future Continence services for children

CHARTC21

Committed to meeting your need for quality products and services


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Welcome to your Home Delivery Service At Charter Healthcare, we offer a fast, discreet and convenient home delivery service. All of your prescription continence and ostomy products can be delivered free to your door within 24-48 hours. To order your products, just call our award-winning Customer Care team on FREEPHONE 0800 132 787 (or 0800 917 8639 for Scotland) and quote CHARTER 21. Alternatively, you can now order products online at www.charterhealthcare.co.uk. Simply register with us at our website and place your order.

For more details, call FREEPHONE 0800 132 787 or visit www.charterhealthcare.co.uk

In association with


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Contents

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Practical care Continence services for children by June Rogers

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Treatment Medications and continence by Valerie Bayliss

Coloplast 11 Charter Healthcare online celebrates its first birthday Straight talking 12 Urinary retention after childbirth by Rona Mackenzie 14 Resources Forum 15 Q&A

Comment

Robbing Peter to pay Paul On 17 February 2010 at the conference ‘Health and Social Care 2010 – High Quality Care for All’ held at Church House Conference Centre, Westminster, London, Andy Burnham, the Secretary of State for Health said: ‘It is a focus on quality that will make services more efficient ... and it is a focus on quality that will move the NHS towards concentrating on prevention as well as cure.’ I would like to look at the particular element, quoted above, of the longer statement that was made by the Secretary of State back in February, as it will affect all our readers and also the wider public. Quality in both the provision of care and the services has always been the aim of all clinicians. Preregistration students In the health in all healthcare professions go into economy there practice with the aim to will be 20% less help and cure people. I believe education funding this year is a key element for all than last year services to sustain quality. As part of the fundamental care of patients, all healthcare professionals should know about basic bladder and bowel function. Unfortunately this is not always the case.

Part of fundamental care The second key issue is the funding of the NHS. In the health economy there will be 20% less funding this year than last year, and the same drop is predicted to occur the following year. This reduction will surely impinge on quality, productivity and performance. Innovation is crucial for the development of the new kind of NHS that is needed, but as a practising clinician I would plead for time to establish change and evaluate if any changes made actually work. Many healthcare initiatives require a culture change for professionals, which normally takes three years to establish. Often, these major changes are being expected Cover picture MONKEY BUSINESS IMAGES/SHUTTERSTOCK

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to happen three to five times a year and, therefore, cannot be properly implemented. The backdrop of all these service changes causes confusion among healthcare professionals and this confusion can, in turn, reflect on patients. Individuals do not always know what is going on and cannot give accurate information to their patient or clients. I remain on the front line as a clinician and have seen the decline in district nursing and the morale of staff – who are constantly having to reapply for their jobs due to excessive restructures – decline dramatically in the last year. I have worked in the NHS for 43 years and have always been optimistic, enjoying the challenges of change; but enough is enough. Staff require some space to develop and implement all these changes.

Interesting and difficult times ahead The second part of the minister’s quotation speaks of preventive care and of empowering the population to remain healthy. There are many new government directives on diet, weight, stopping smoking and keeping fit that are either under way or about to launch. The key elements of these new drives will be education and support but, again, this will require additional funding. It does not take a mastermind to understand that you will have to rob Peter to pay Paul to achieve this. The next few years will be interesting for all of us. No, I do not have any answers to the problems that face us all, but I will do my best to ensure the care given is of high quality. However, we all get a chance to change opinions of ministers by visiting our local MPs’ surgeries and I would encourage everyone to do so in order to get their voices across on specific issues that they are concerned about. Whether it is a local issue, such as reopening public toilets, or a larger national issue, such as asking if there will be free products available in the future, I encourage people to make their voices heard on the things that they care about. In this issue we have articles by some of those underpressure healthcare professionals I have spoken about in this comment and I thank them for contributing in these very busy and often stressful times.

Ann Winder, Editor The Editor Charter continence care Hayward Medical Communications 8–10 Dryden Street London WC2E 9NA email: edit@hayward.co.uk

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continence care Publication of Charter continence care is made possible through the support of Coloplast Limited. Editor Ann Winder RN Senior Continence Specialist, Park Drive Health Centre, Baldock Editorial Board Liz Bonner RN DNCert BSc(Hons) BA(Hons) HV MSc Nurse Consultant (Bladder/Bowel Dysfunction), Bedfordshire Continence Service, Dunstable Mary Brown RGN BA(Hons) PGCE Continence Nursing Team Manager, NHS Lothian Michael Cogswell Paraplegic, Pluckley, Kent Rachel Busuttil Leaver BSc(Hons) RN PGCE Lecturer Practitioner in Urological Nursing, London South Bank University and University College London Hospitals Sunil Mathur BA(Hons) MBBS MRCS Specialist Registrar, Musgrove Park Hospital, Taunton Mark Slack MB ChB MMed MRCOG FCOG(SA) Consultant Urogynaecologist, Addenbrooke’s Hospital, Cambridge Paul Smith Executive Director, Spinal Injuries Association

Editorial Director Elaine Bennett. Chief Sub Joel Barrick. Senior Sub Editor Anne-Claire Bouzanne. Sub Editor Christian Bell. Editorial Assistant Danielle Colyer. Art Editor Richard Seymour. Art Director Andrina de Paiva. Publisher Keena McKillen. The data, opinions and statements appearing in the articles herein are those of the contributor(s) concerned; they are not necessarily endorsed by the sponsor, publisher, Editor or Editorial Board. Accordingly, the sponsor, publisher, Editor and Editorial Board and their respective employees, officers and agents accept no liability for the consequences of any such inaccurate or misleading data, opinion or statement. Published by Hayward Medical Communications, a division of Hayward Group Ltd, The Pines, Fordham Road, Newmarket CB8 7LG. Tel: 01638 723560. Fax: 01638 723561. email: admin@hayward.co.uk Design & Editorial Office Hayward Medical Communications, 8–10 Dryden Street, London WC2E 9NA. Tel: 020 7240 4493. Fax: 020 7240 4479. email: edit@hayward.co.uk Copyright © 2010 Hayward Group Ltd. All rights reserved. ISSN 1745-9982. Printed by Turners.

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Practical care

Continence services for children The continence services and products available for children have not always been as comprehensive as they are today. June Rogers explains how things have evolved The development of community-based continence services in the UK began in the early 1980s when it was recognised that the provision of care for people with bladder and bowel problems was poor. However, the initial focus was very much towards the elderly population and provision of products for that age group. It was not until the late 1990s that continence services aimed specifically at children began to emerge. A review of all UK continence services was undertaken in 1998, by the then Parliamentary Under-Secretary of State, Mr Paul Boateng, as it was found that the focus of continence care was still management of the problem with pads, rather than identification of the underlying cause followed up by appropriate treatment. As a result of the review, a working group was set up with the remit of updating the original guidance on continence services issued by the Department of Health in 1991. This working group culminated in the publication of the document Good practice in continence services in 2000.1 This guidance set out a model of good practice to help achieve more responsive, equitable and effective continence services to benefit patients. The guidance also called for integrated, cohesive and comprehensive continence services, in hospital, at home and in care, encompassing the treatment of urinary and faecal incontinence in all age groups. Services were to be founded on agreed evidence-based policies, procedures and guidelines with group audit and review. Also included in this document were recommendations for joint targets for children between health and local authorities. The working group recommended that arrangements be put in place to ensure that children are not excluded from preschool or school educational activities solely due to their incontinence. Despite all the recommendations, the development of paediatric continence promotion services was a very slow process. In 2003, a scoping exercise took place that reviewed the services for children with continence problems in England. The findings from this study identified that, although there were areas of excellence and good practice, the

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service provision for children with bladder and bowel problems was very patchy and, overall, very poor; with many services offering patients little more than free nappies. The findings of this work led to the publication of Good Practice in Paediatric Continence Services – Benchmarking in Action,2 which then went on to inform the Children’s National Service Framework (CNSF).3 The benchmarking document sets out what is considered to be best practice in caring for a child with a continence problem – it can be freely downloaded from the internet2 and parents should be encouraged to use it as evidence if they feel that there is lack of adequate care for children in their area. The CNSF recommended that: ‘An integrated community-based paediatric continence service, informed by Good Practice in Paediatric Continence Services, ensures that accessible, highquality assessment and treatment is provided to children and their parents/carers in any setting, including, for example, looked-after children and children at boarding schools’.3 A number of exemplars, linked to the CNSF, have been developed. These include an example of the journey through services that a child with continence problems should experience.

June Rogers MBE RN RSCN BSc(Hons) MSc ENB 978 ENB NO1 ENB 216

PromoCon Team Director

Paediatric services The number of paediatric continence services that are evolving across the country are slowly increasing. Ideally, these services should be developed to include all aspects of bladder and bowel care, with a strong focus on prevention and early intervention, rather than just the provision of products. Most of the services are open access, enabling parents to refer their children themselves if necessary, and cover children from newborn to 19 years of age, including children in special schools. Although the majority of continence services for children sit within, or run alongside, adult continence services, in some areas they are within the local children’s services directorate. Also, many areas may only have services for children with specific problems, such as bedwetting, which are usually run separately by the school nurses, with no direct link to the

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Practical care

Provision of products

Continence services for children now offer a wide range of services, but this was not always the case

Many of the calls to helplines, like PromoCon (see Box 1), are from parents concerned about the provision of pads, and/or nappies, for their children. This is often related to either the type, or number, of products supplied. Within the UK, most continence services provide disposable continence products to children once they reach the age of four or five years, depending on local policy. The recommendations from the Department of Health are that, before the issuing of any products, the child should undergo a thorough continence assessment. This is important to ensure that any underlying problems are excluded and the child’s individual needs are fully identified. The old practice of a healthcare professional filling in a form and ticking boxes to arrange a supply of ‘free nappies’ for the child is no longer acceptable, and should not be taking place. The exact type, and number, of products supplied should be very much dependent on a child’s individual needs. However, we have to realise that, in the real world, provision of products is often restricted by budgetary and formulary restraints. However, despite inherent limitations, by identifying individual needs and providing products appropriately, there should, in theory, be very little wastage–enabling services to work towards meeting individual needs as much as possible. There is now a range of products available, other than the conventional nappy style. A two-piece system comprising of a disposable pad and fixation pants may be the option for some children, rather than an all-in-one nappy. This system allows for more independence and is much easier to change than a one-piece nappy. For some children with only a wetting problem, a washable product comprising of ‘normal’ underwear with a built-in pad may be most appropriate, particularly for a school-age child who does not want to be seen to be ‘different’. Some areas may be restricted to supplying products from one particular manufacturer only. However, most manufacturers have a wide range available. If a parent feels that a particular product supplied is not meeting their child’s needs, they should ask to see what other products are available from their local continence service.

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continence service. As services for children with continence problems differ so greatly across the country, parents should, in the first instance, contact their health visitor or school nurse to see what is available in their local area.

Specific problems Bedwetting Bedwetting has traditionally come under the remit of school nurses and, in some areas, health visitors. Even if a dedicated paediatric continence service is not available for children in a specific area, there is usually a service for children with bedwetting either run as a nurse-led service or as a combined doctor/nurse service. The problem is that, often, a service only covers children with bedwetting and, if a child has additional problems (such as constipation or daytime wetting) they cannot be seen. For children with bedwetting the majority of services will see children aged from five to 16, or children up to age 18 in some areas, depending on local policy. Most services include assessment and treatment programmes and usually have equipment, such as enuresis alarms, which can be lent out free of charge to families for a period of about four to six months.

Constipation and soiling Constipation and soiling in childhood has been recognised as being among the most common of childhood complaints, but it has also been acknowledged as a condition that has the most varied and ad hoc approach to treatment. The recognition has been so great, that the National Institute for Health and Clinical Excellence (NICE) is currently developing guidelines for the treatment of idiopathic constipation and soiling in childhood,4 which should be launched by May 2010. NICE is also preparing guidelines for bedwetting,5 which should

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Practical care be available towards the end of 2010. In the meantime, a working group has put together the IMPACT Paediatric Bowel Care Pathway6 to help practitioners manage this distressing problem more effectively – information can be found online (www.childhoodconstipation.com). It is important that treatment for constipation is not delayed, as there is a risk it could become chronic with the child ending up so ‘bunged up’ or impacted that they cannot open their bowels at all. A sign that this is happening is when the child starts to soil themselves. Although increasing fluid and fibre intake in the diet is helpful in preventing constipation from developing – the only effective treatment once constipation has developed is to give laxatives (drugs taken to induce bowel movements). Families should be encouraged to contact their healthcare professional if they have any concerns that their child may be becoming constipated.

Neuropathic bladder and/or bowels Children born with congenital abnormalities, such as spina bifida, also have an associated problem with their bladder and bowels that often results in incontinence. These children can be obviously identified at birth and initial assessments and treatments are normally carried out in hospital. Ideally, links should also be made with community services to ensure appropriate follow-up and support. Who those links are made with depends very much on what specific services are available – if specialist paediatric continence services are not available, then, often, community care of these children falls under the remit of the community paediatric nursing services. Many infants with congenital abnormalities are transferred at birth to regional centres for treatment, often many miles from home and sometimes in an outside trust. In these cases, those working in the acute hospital setting should aim to identify, as soon as possible, appropriate healthcare professionals in the child’s own local area to refer the child to following discharge and ensure appropriate support. If local specialist services are unable to provide appropriate support, then it is vital that those who are involved with the child’s care ensure that they have had the appropriate training to do so.

Key points ● It was not until the late 1990s that continence services specifically aimed at children began to emerge in the UK. ● Most of the services are open access, enabling parents to refer their children themselves, if necessary, and cover children from newborn to age 19, including children in special schools. ● An increasing number of nurses have an interest in paediatric continence promotion and, as a result, the provision of continence care to children is rapidly improving.

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Box 1. PromoCon – contact details PromoCon, Disabled Living, St Chads Street, Cheetham, Manchester M8 8QA Helpline: 0161 834 2001 (Monday–Friday 10 am–3 pm) Fax: 0161 835 3591 email: promocon@disabledliving.co.uk website: www.promocon.co.uk

Continence care in schools Historically, many children who required ongoing medical and/or nursing care, such as intermittent catheterisation, went to a ‘special school’ but, from the mid-1990s onwards, the push towards fully-inclusive education has meant that the majority of these children are now attending mainstream schools. This obviously has implications for the child that needs help with personal care, including with activities such as going to the toilet or being catheterised. Schools have a duty-of-care towards meeting the needs of all children and systems need to be put in place so that the child has the support that they require while in school. Schools should not expect parents to have to come in to the school to change or catheterise their child, as this is no longer acceptable practice. The document Including me: Managing complex health needs in schools and early years settings,7 sets out examples of best practice and provides guidance for schools regarding managing children with complex health needs. Following on from the ‘Including me’ guidance, PromoCon put together another document that sets out duties for both school and parents regarding supporting a child with more complex toileting needs (such as catheterisation or stoma care).8 Included in this document are examples of training schedules for carers. There is now an increasing number of nurses who have an interest in paediatric continence promotion and are developing specific skills and expertise in this area and, as a result, the provision of continence care to children is rapidly improving ■ References 1. Department of Health. Good practice in continence services. London: DH, 2000. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/docu ments/digitalasset/dh_4057529.pdf (last accessed 08/03/10) 2. NHS Modernisation Agency. Good Practice in Paediatric Continence Services – Benchmarking in Action. London: NHS Modernisation Agency, 2003. http://collections.europarchive.org/tna/20081112112652/www.cgsupport.nhs.uk/ PDFs/articles/good_practice_paediatric_continence_services.pdf (last accessed 08/03/10). 3. Children’s National Service Framework. http://www.dh.gov.uk/en/Healthcare/Children/DH_4089111 (last accessed 08/03/10) 4. National Institute for Health and Clinical Excellence. Constipation in children http://www.nice.org.uk/Guidance/CG/Wave14/21 (last accessed 08/03/10) 5. National Institute for Health and Clinical Excellence. Nocturnal enuresis in children (bedwetting) http://guidance.nice.org.uk/CG/Wave15/79 (last accessed 08/03/10) 6. Rogers J. The impact paediatric bowel care pathway. Nurs Times 2008; 104: 46–47. http://www.nursingtimes.net/nursing-practice-clinical-research/the-impactpaediatric-bowel-care-pathway/1329051.article (last accessed 08/03/10) 7. Carlin J. Including me: Managing complex health needs in schools and early years settings. London: The Council for Disabled Children, 2005. http://nationalstrategies.standards.dcsf.gov.uk/node/84492 (last accessed 08/03/10) 8. PromoCon. Managing Bowel and Bladder Problems in Schools and Early Years Settings. Guidelines for good practice. Manchester: PromoCon, 2006. http://www.promocon.co.uk/PromoconBooklet.pdf (last accessed 08/03/10)

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Treatment

Medications and continence People are often unaware that medicines they are taking for other problems may be the source of their continence problems. In this article, Valerie Bayliss explains why

Valerie Bayliss RN MSc Clinical Nurse Specialist, Hampshire Community Health Care, Basingstoke

This article describes the effects that different medications can have on continence. The idea is to inform people about side-effects that may occur (rather than will occur) and no-one should stop taking any medication that they have been prescribed by their doctor without discussing it with them first. The side-effects listed here are not common, but it is useful to be aware of them.

Allergies, hay fever and nettle rash Some medications, known as antihistamines, sold for allergies (such as nettle rash or hay fever) can make it harder to empty the bladder, which can lead to retention of urine in susceptible people. Common antihistamines that are used include chlorphenamine, promethazine and clemastine.

Coughs and colds

Over-the-counter medicines Over-the-counter medicines can be bought from a chemist without the need for a prescription from a doctor. Many medicines contain ingredients that make you feel better, but these can also affect the way that your bladder empties. The most common side-effect of these medicines is that they stop the bladder from reducing in size (contracting) sufficiently when you feel that you want to pass urine. If the bladder cannot contract properly this may mean that you have to strain, or push, in order to completely empty it, or that the stream of urine comes in fits and starts. You may also need to wait longer than normal to finish urinating as the stream produced will not be as strong as it should be. A little urine may also remain in the bladder after you think you have finished urinating and this will cause you to urinate more frequently; this problem should resolve when you stop taking the medication. However, if you cannot pass urine at all you should stop the medication immediately and contact your doctor. It may be better for anyone with a predisposition to incomplete bladder emptying, such as men with prostate problems, to avoid taking medicines mentioned here if alternatives are available. Some over-the-counter painkillers can cause constipation. For people who are already susceptible to urinary urgency or frequency, constipation can make these symptoms worse. This is because a build-up of stool in the rectum will press against the bladder, making less room for the storage of urine. Extreme constipation can lead to diarrhoea, which can be difficult to control. A laxative, as well as plenty of fluids, fruit and vegetables, may be needed to avoid constipation when taking any codeine-based painkillers (see Table 1).

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Many medications for colds and coughs can cause difficulty passing urine – mostly in men with prostate problems, but also in others. The ingredient that can cause difficulty in passing urine is pseudoephedrine and this will be listed on the packaging of drugs that contain it.

Travel sickness Motion sickness tablets, or patches, often contain an ingredient called hyoscine. Hyoscine helps to stop nausea and vomiting, but may also cause difficulty in passing urine.

Prescription medications The action of prescription medications needs to be more effective than over-the-counter medicines and some can have more significant side-effects. For example, you can buy cocodamol from the chemist that is 8 mg codeine and 500 mg paracetamol and this may cause mild constipation; but your doctor can prescribe co-codamol that contains 30 mg codeine, which will certainly cause constipation and measures against this can be taken at the time of prescription. Discuss this with your doctor to identify a suitable prevention strategy. The higher the dose of your medication, the more substantial the side-effects may be. Please consult the table that follows to see if your prescription appears. Note that chemical names of the medicines are used, not the trade names. If you think you may be experiencing side-effects from prescribed medication, talk to your doctor who may be able to prescribe a different type. Under no circumstances stop taking prescribed medication, as you have been identified by your doctor as needing it and may become very ill if you do not take it as has been recommended â– 

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Table 1. Medications that can affect continence Medication

Indication/s

Side-effect/s

Alimemazine tartrate Alprazolam Alprostadil Amantadine hydrochloride Amiloride hydrochloride Amitriptyline Amlodipine besilate Amoxapine Atropine sulphate Baclofen Benzatropine mesilate Brompheniramine (ingredient of cough linctus) Buprenorphine Carbidopa Carmustine implant Carvedilol Chlordiazepoxide Chlorphenamine maleate Chlorpromazine hydrochloride Chlortalidone Citalopram Clemastine Clomipramine hydrochloride Clonazepam Clozapine Cyclopenthiazide Cyproheptadine hydrochloride Dantrolene sodium Darifenacin Diazepam Dicycloverine Dihydrocodeine tartrate Diphenhydramine hydrochloride Dipipanone Disopyramide Donepezil hydrochloride Dosulepin hydrochloride Dothiepin hydrochloride Doxazosin Doxepin Doxylamine Eletriptan Ephedrine hydrochloride Escitalopram Etodolac Felodipine Fentanyl Flavoxate hydrochloride Flurazepam Frovatriptan Gabapentin Galantamine Hydroxyzine hydrochloride Hyoscine butylbromide Hyoscine hydrobromide Imipramine Indapamide Indoramin Isocarboxazid

Allergies, urticaria, pruritus Anxiety Erectile dysfunction Influenza, Parkinson’s disease Hypertension, oedema, congestive cardiac failure (CCF) Depressive illness Hypertension, angina prophylaxis Depressive illness Gastrointestinal (GI) spasm Muscle spasticity Parkinson’s disease Allergies Pain Parkinson’s disease Glioma Chronic heart failure, hypertension, angina Anxiety Allergies Psychosis, mania, schizophrenia Hypertension, oedema, CCF, diabetes insipidus Depressive illness, obsessive–compulsive disorder Allergies Depressive illness, phobic states Epilepsy Schizophrenia Hypertension, oedema, CCF Allergies Muscle spasticity, malignant hyperthermia Bladder instability Anxiety, insomnia, muscle spasm Irritable bowel syndrome, GI spasm Pain Allergies Pain Ventricular arrhythmias Alzheimer’s (dementia) Depressive illness Depressive illness Hypertension Depressive illness Cough, decongestant Migraine Hypotension, nasal congestion Depressive illness, obsessive–compulsive disorder Osteo- and rheumatoid arthritis Hypertension, angina prophylaxis Breakthrough pain Urinary frequency Insomnia Migraine Epilepsy Alzheimer’s (dementia) Allergies, pruritus, anxiety Diverticular disease Motion sickness Depressive illness Hypertension, oedema, CCF Hypertension Depressive illness

Difficulty urinating, urinary retention Urinary retention, decreased awareness, incontinence Frequency, urgency, impaired urination Incontinence, urinary retention Urinary frequency and urgency Difficulty urinating Urinary frequency Difficulty urinating Urinary urgency Urinary incontinence, urinary retention Urinary retention Difficulty urinating, urinary retention Difficulty urinating Incontinence, urinary retention Urinary tract infection, incontinence Incontinence (in females) Urinary retention, decreased awareness, incontinence Difficulty urinating, urinary retention Difficulty urinating Urinary frequency and urinary urgency Urinary retention Difficulty urinating, urinary retention Difficulty urinating Urinary incontinence Difficulty urinating Urinary frequency and urinary urgency Difficulty urinating, urinary retention Urinary frequency, incontinence, urinary retention Urinary retention, bladder pain Urinary retention, decreased awareness, incontinence Urinary urgency Urinary retention Difficulty urinating, urinary retention Difficulty urinating Urinary retention Urinary incontinence Difficulty urinating Difficulty urinating Incontinence Difficulty urinating Difficulty urinating, urinary retention Urinary frequency, polyuria Urinary retention, difficulty in urinating Urinary retention Urinary frequency, dysuria Urinary frequency Urinary retention Difficulty urinating Urinary retention, decreased awareness, incontinence Urinary frequency, polyuria Incontinence Urinary tract infection Difficulty urinating, urinary retention Urinary urgency Difficulty urinating Difficulty urinating Urinary frequency and urgency Urinary frequency, incontinence Difficulty urinating

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Table 1. Continued Medication

Indication/s

Side-effect/s

Isoniazid Lacidipine Levomepromazine Lithium Lofepramine Loprazolam Lorazepam Lormetazepam Maprotiline Meptazinol Methadone hydrochloride Metolazone Mianserin Morphine sulphate Nicardipine hydrochloride Nifedipine

Pulmonary tuberculosis Hypertension, angina prophylaxis Schizophrenia Bipolar disorder, mania Depressive illness Insomnia, anxiety Anxiety, insomnia Insomnia Depressive illness Pain Opioid dependence Hypertension, oedema, CCF Depressive illness Pain Hypertension, angina prophylaxis Hypertension, angina prophylaxis, Raynaud’s syndrome Hypertension, angina prophylaxis Insomnia Depressive illness Schizophrenia Parkinson’s disease Anxiety Bladder instability Pain Schizophrenia Pain Pain Schizophrenia and other psychoses Schizophrenia and other psychoses Depressive illness Hypertension, Raynaud’s syndrome, CCF Neuropathic pain, epilepsy, generalised anxiety disorder Parkinson’s disease Agitation and restlessness Allergies GI spasm Urinary frequency, urinary urgency Parkinson’s disease Depressive illness, anxiety Psychoses, mania Urinary frequency, urinary urgency Growth failure Arthritis, inflammatory disorders Insomnia Hypertension, benign prostatic hyperplasia Urinary frequency, urinary urgency Depressive illness Depressive illness Hypertension, oedema CCF Parkinson’s disease Allergies Depressive illness Cough, decongestant Urinary frequency, urinary urgency Depressive illness, generalised anxiety disorder Hypertension, oedema CCF Migraine

Difficulty urinating Urinary frequency Difficulty urinating Polyuria Difficulty urinating Urinary retention, decreased awareness, incontinence Urinary retention, decreased awareness, incontinence Urinary retention, decreased awareness, incontinence Difficulty urinating Difficulty urinating Difficulty urinating Urinary frequency and urgency Difficulty urinating Difficulty urinating Urinary frequency Urinary frequency

Nisoldipine Nitrazepam Nortriptyline Olanzapine hydrochloride Orphenadrine Oxazepam Oxybutynin hydrochloride Oxycodone hydrochloride Paliperidone Papaveretum Pentazocine Pericyazine Phenelzine Pipotiazine palmitate Prazosin Pregabalin Procyclidine hydrochloride Promazine Promethazine hydrochoride Propantheline bromide Propiverine hydrochloride Rasagiline mesilate Reboxetine Risperidone Solifenacin succinate Somatropin Sulindac Temazepam Terazosin Tolterodine tartrate Tranylcypromine Trazodone Triamterene Trihexphenidyl hydrochloride Trimeprazine tartrate Trimipramine Triprolidine Trospium chloride Venlafaxine Xipamide Zolmitriptan

Urinary frequency Urinay retention, decreased awareness, incontinence Difficulty urinating Urinary hesitation Urinary retention Urinay retention, decreased awareness, incontinence Difficulty urinating Urinary retention Urinary incontinence Difficulty urinating Difficulty urinating Difficulty urinating Difficulty urinating Difficulty urinating Urinary frequency, incontinence Urinary incontinence, dysuria Urinary retention Difficulty urinating Difficulty urinating, urinary retention Urinary urgency Difficulty urinating Urinary urgency Urinary retention Incontinence Difficulty urinating Incontinence, urinary frequency Dysuria Urinary retention, decreased awareness, incontinence Urinary frequency, incontinence Difficulty urinating Difficulty urinating Difficulty urinating Urinary frequency and urgency Urinary retention Difficulty urinating, retention Difficulty urinating Difficulty urinating, retention Difficulty urinating Urinary frequency Urinary frequency and urgency Urinary frequency, polyuria

Table reproduced by kind permission – Bayliss V, Locke R, Salter E. Continence Care Pathways. John Wiley and Sons, 2009.

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Charter Healthcare online celebrates its first birthday Charter Healthcare provides an invaluable service to communities, including healthcare professionals, worldwide. It’s hard to believe the online service is just one year old Charter Healthcare is celebrating one year of offering an online ordering service. The online service, which was launched in April 2009, allows healthcare professionals and endusers to order their prescription continence and ostomy products for a 24–48 hour delivery. The service provides an alternative method of ordering to the popular telephone ordering service, which customers can call on 0800 132 787. ‘Our online ordering service is the fastest, most discreet and convenient way for customers to order their products. It’s exceptionally smart as you can save all your orders, making repeat ordering much easier. Over 3,000 customers are currently using the service and its popularity continues to grow,’ says Blair Cheekooree, Marketing Communications Manager. You can read the Charter journals, both Charter continence care and Charter stoma care, online at your own leisure and even forward copies to It’s very easy to sign up to online other people who you think would ordering. You can visit find it useful. Charter continence Over 3,000 customers are www.charterhealthcare.co.uk care is one of the UK’s most widely read patient journals, where you can create a username currently using the service and its with over 74,000 people and password to set up an popularity continues to grow receiving it each quarter. account. Next, you can input your The online service allows you to address, date of birth and GP information, browse thousands of products – including continence, which is then saved so that you do not need to input it ostomy, wound and skincare ranges. Users can request free again. You are then ready to start ordering your products and Charter Healthcare can even request your prescription for you product samples via the website. There are many useful videos to save time. Every time an online order is placed, you will be to watch within the different product areas; the newest is given a unique number, which is specific to your order. about Peristeen Anal Irrigation, which is the market-leading bowel management system. You can also download a range of Sign up today (at www.charterhealthcare.co.uk) to start literature from the website: everything from educational ordering your products: anal irrigation, catheters, sheaths, material to product information. urine drainage bags and accessories ■

CHARTER CONTINENCE CARE ISSUE 21

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Straight talking

Urinary retention after childbirth Although they are not mentioned very often, bladder problems following pregnancy can be extremely serious and need to be treated promptly and carefully

SRN DN Cert Cert Ed (FE) BA(Hons) Clinical

Nurse Specialist Continence, The Princess Alexandra Hospital NHS Trust, Harlow

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Women rarely consider that they may have difficulty in passing urine after childbirth, but it is a problem. There has been limited research on the subject, however, and guideline development has largely been left to individual maternity units. In 1991, studies showed that 1.7–17% of women were unable to empty their bladders fully after childbirth.1 Less than 1% of women are unable to pass urine at all after giving birth and need to be catheterised.2 Hormonal changes in pregnancy cause the bladder muscle to lose tone and, therefore, capacity increases from the third month. This increase may not be obvious to the woman who, due to pressure from an enlarging uterus, will need to go to the toilet more often. However, after delivery, the loss of muscle tone can cause difficulties in emptying the bladder fully. Avoidance and proactive management of urine retention should begin during pregnancy and it is important that midwives identify the following groups of women. ● Women who have pre-existing bladder problems or use an intermittent catheter (a small tube inserted into the bladder to drain the urine, which can then be removed). ● Women with a large capacity bladder who pass urine infrequently (four times or less a day) and pass large volumes of urine (more than 600 ml each time they urinate). ● Women who have experienced bladder problems following a previous delivery. Identifying these groups will allow time to give advice and plan bladder care. The events that may contribute to the development of difficulties in passing urine are: ● Epidural analgesia (the injection of anaesthetic through a catheter placed into the outermost part of the spinal canal) for pain relief ● Long labour ● Prolonged second stage of labour ● Forceps or vacuum-assisted vaginal delivery ● Extensive vaginal wounds and cuts.3 Changes to drug combinations and dosage used in epidurals in some maternity units may reduce the risk of bladder problems occurring. Epidural analgesia or spinal anaesthetic (an injection of a local anaesthetic into the spine) both block normal sensation from the bladder and interfere with its normal processes.

A new baby brings joy, but women can suffer serious bladder problems after giving birth

DIGITAL VISION/GETTY IMAGES

Rona Mackenzie

During labour During labour, women should be encouraged to pass urine every two hours or before top-up of their epidural (if they have one). If the woman cannot pass urine after two attempts, an intermittent catheter should be used to empty the bladder. Midwives will record the times and volumes of urine passed. An indwelling urethral catheter (that can be left in the bladder) connected to a continuous drainage bag can be used if labour is long. An indwelling catheter has a small balloon attached, which is inflated after insertion into the bladder, to stop it sliding out. In some maternity units, all women who have an epidural have an indwelling urethral catheter. To avoid damage to the bladder neck or urethra, the catheter must be removed before delivery. Women who need instrumental (in other words, vacuum- or forceps-assisted) delivery, who are not catheterised, must have their bladder emptied in advance by intermittent catheter. If an epidural is in place the urethral catheter must be replaced after delivery.

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Straight talking After caesarean or epidural More women than ever are having caesareans, and/or epidurals, meaning that they now experience altered bladder sensation after delivery. Bladder sensation may take over ten hours to return after a caesarean under spinal analgesia and over six hours after vaginal delivery.4 Advice on catheter removal varies. For women who have a caesarean section under spinal analgesia, the catheter should be left in for at least 12 hours after the last top-up dose and until she is mobile again.5 After vaginal delivery it should remain in place for a minimum of six hours after the last top-up, or discontinuation of epidural or spinal analgesia. If removal is due to take place after 10 pm, then the catheter should remain in overnight. Retention of urine after caesarean section does occur, even though women will have been catheterised for 12–24 hours after delivery.6 Women most at risk of urinary retention are those who have had an emergency section.

After natural birth Women who give birth without an epidural are advised to pass urine within six hours of delivery.7 Encouragement after four hours allows time for simple measures to be tried first, such as: pain relief, getting out of bed and walking about, or having a warm bath. The advice for women who cannot pass urine, or can only pass small amounts, after six hours is an ultrasound bladder scan or catheterisation. There is no agreement as to how much urine left in the bladder after passing urine (residual urine) is considered significant, or on the action needed to resolve this. Indwelling urethral catheterisation is the main solution used to solve residual urine problems, but the length of time that the catheter is left in place varies in different maternity units. Indwelling catheters allow continuous drainage into a bag, stopping the bladder from filling and allowing it to rest. Intermittent catheters allow drainage via a valve, so the bladder can fill and empty in a normal cycle. However, having a catheter in the urethra prevents normal passing of urine. The risk of urinary tract infection is increased when the catheter enters the bladder via the urethra, due to bacteria around the vagina and anus. Women sent home with a catheter in place are given an appointment to return for its removal. During this period, women are advised to drink about two litres of water every 24 hours. Excessive fluid intake and intravenous fluids given during labour will increase the urine production and the speed at which the bladder fills. On the second to fifth day after delivery, the body gets rid of the fluids retained as part of normal pregnancy, so more urine will be produced.

Alternative management Another option for women is suprapubic catheterisation (SC). This type of catheter enters the bladder through the abdominal wall and may be left in place for up to six weeks.8 A benefit of SC with intermittent drainage is that women can also try to pass urine voluntarily; any urine left in the bladder can then be drained via the catheter.

CHARTER CONTINENCE CARE ISSUE 21

Intermittent catheterisation (IC) has not been generally adopted following childbirth, but has been successfully used in a few maternity units.9,10 Women try to pass urine and then a catheter is used to drain any residual urine; both volumes are recorded. The routine is continued every four to five hours during the daytime, allowing the bladder to follow its normal cycle. Catheterisation stops when residual amounts of urine reduce to 100–150 ml. IC using a coated catheter is more comfortable than using an indwelling urethral catheter. Coated catheters are less prone to infection and do not interfere with the management of vaginal bleeding (which is normal after delivery). Women can be taught to self-catheterise to prevent delayed discharge from hospital. Having a catheter inserted can cause distress, and options must be discussed before treatment begins. Early discharge from hospital may result in women returning with problems that were not clear in the first 48 hours after delivery. Questioning by hospital staff can also reveal that constipation is the underlying cause of bladder issues.

Be vigilant Women should be advised of the risk of developing bladder problems after childbirth. All maternity services should have guidelines in place to help reduce the risk of urinary retention and take prompt action if required ■ References 1. Saultz JW, Toffler WL, Shackles JY. Postpartum urinary retention. J Am Board Fam Pract 1991; 4: 341–344. 2. Andolf E, Iosif CS, Jörgensen C, Rydhström H. Insidious urinary retention after vaginal delivery: prevalence and symptoms at follow-up in a population-based study. Gynecol Obstet Invest 1994: 38: 51–53. 3. Yip SK, Brieger G, Hin LY, Chung T. Urinary retention in the post-partum period. The relationship between obstetric factors and the post-partum post-void residual bladder volume. Acta Obstet Gynecol Scand 1997; 76: 667–672. 4. Foon R, Toozs-Hobson P, Powles K. Uncharted territory: Anaesthesia and the urinary bladder after delivery. Neurourol 2008; 27: 672–674. 5. National Collaborating Centre for Women’s and Children’s Health. Caesarean Section. Clinical guideline. London: RCOG press. http://guidance.nice.org.uk/CG13/Guidance/pdf/English (last accessed 08/03/10) 6. Chai AH, Wong T, Mak HL et al. Prevalence and associated risk factors of retention of urine after caesarean section. Int Urogynecol J Pelvic Floor Dysfunct 2008; 19: 537–542. 7. RCOG Study Group Recommendation. Incontinence in Women. London: RCOG Press 2002 Ch 12:154–155. MacLean AB, Cardozo L (eds). In: Incontinence in Women. London: RCOG Press, 2002. 8. Balmforth J, Bidmead J, Cardozo L, Robinson D, Parsons M. First do no harm. Poster presentation at International Continence Society (UK) 12th Annual Scientific Meeting, Glasgow, 2005. 9. Glavind K, Bjørk. Incidence and treatment of urinary retention postpartum. Int Urogynecol J Pelvic Floor Dysfunct 2003; 14: 119–121. 10. Mackenzie R. Improving continence service standards within midwifery. Br J Nurs 2002; 11: 1205–1206, 1208, 1210–1211.

Key points ● Urinary retention can affect any woman following childbirth. ● Women who give birth without an epidural should pass urine within six hours of delivery. ● Management options for urinary retention vary between maternity units.

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Resources ■ Association

for Continence Advice

■ Disabled Living

Foundation

■ Multiple

Sclerosis Trust

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The Association for Continence Advice (ACA) is the only multiprofessional association focusing on the education of professionals interested in continence. Urinary incontinence affects some 20% of community-dwelling older people and 30–60% of those in institutional care. Incontinence is associated with a range of medical conditions, many of which become more common with increasing age, affecting the quality of life of patients and their carers. We offer members continuing professional education and development through our newsletter (published four times a year), study days, an annual conference, our Notes on Good Practice (peer reviewed) and access to modular

continence courses by e-learning through links with the University of Ulster. We are also involved with the All-Party Parliamentary Group for Continence Care and the government’s Prevention Package for Older People. Recent activities include the development of an information leaflet for teenage girls, catheter consensus guidelines, rectal irrigation guidelines and a two-year research project relating to the levels of undergraduate continence education funded by the Dunhill Medical Trust. To find out more please log on to the ACA website. Tel: 01506 811 077. email: info@fitwise.co.uk website: www.aca.uk.com

The Disabled Living Foundation (DLF) is one of 50 disabled living centres around the UK that provide free, impartial advice about disability equipment and mobility products for older and disabled people, their carers and families. The DLF offers an online self-assessment tool, AskSARA (SARA stands for Self Assessment, Rapid Access), an innovative way for you to obtain advice about equipment that can help in your daily life. It asks you to enter details, then provides you with a report based on your answers. You will get ideas of ways to make your life easier and of products that might help. One of the key new features is the use of images to give a better idea of the products and how to use them. The details have been updated

with the help of occupational therapists, who have ensured that AskSARA contains the most up-to-date and relevant information. The DLF offers 45 fact sheets online, including one on ‘Clothing for continence and incontinence’. The DLF runs an Equipment Demonstration Centre in West London and responds to up to 25,000 requests for information every year. Tel: 0207 289 6111 (Mon–Fri; 9 am–5 pm). Helpline: 0845 130 9177 (Mon–Fri; 10 am–4 pm). email: info@dlf.org.uk or advice@dlf.org.uk websites: www.dlf.org.uk www.asksara.org.uk www.livingmadeeasy.org.uk

The Multiple Sclerosis Trust (MS Trust) is a charity working with, and for, all people in the UK affected by multiple sclerosis (MS). Our vision is to enable people with MS to live their lives to the full. We provide: • Information tailored to what people want to know • Education for healthcare professionals about what people with MS need • Research into better management of MS • Support for anyone affected by MS. We answer a wide range of enquiries and aim to provide reliable, evidence-based information that helps people make informed decisions about their care and treatment. We publish a range of free books, DVDs and fact sheets on MS, its symptoms and living with the condition. Bladder and bowel

problems are common symptoms of MS and we have fact sheets on both topics. We also publish Open Door, a free, quarterly newsletter, and have email alert services to keep people up to date with MS news and research. Our website is packed with information, including an A to Z of MS, information for people recently diagnosed, a map of MS services and much more. MS Trust funding supports applied research – research that brings essential therapies to people who have to cope with MS every day of their lives, or which demonstrates how better services can be provided. Tel: 01462 476 700. email: info@mstrust.org.uk website: www.mstrust.org.uk

CHARTER CONTINENCE CARE ISSUE 21


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In conversation with … If you have a question about managing incontinence, our Editorial Board members are here to help. We want to hear from you, so write to us at the address below Ann Winder RN Senior Continence Specialist, Park Drive Health Centre, Baldock

My husband has a suprapubic catheter in situ, which has caused him to suffer frequent urinary infections. The catheter was frequently blocked and needed changing as often as every ten days. It could never be left in place for more than 14 days. After suggestions from various sources (all people working in the field of urology) we have adopted the following regime. We discontinued use of a valve, instead connecting the catheter directly to the day and night bag. We began to use filtered water in the catheter – ours being a very hard water area. My husband drinks a glass of water with a fresh lemon squeezed into it daily and has switched to decaffineated coffee and tea. So far, this has been successful and has extended the time a catheter can be kept in place to six to eight weeks. I am writing to you in the hope that these suggestions may be of use to someone in a similar situation.

Ms P, Essex Thank you very much for your letter. I’m glad you and your husband have had relief from your annoying catheter problems and we are more than happy to share the solutions that you have found useful with our readers ■ I have had a catheter for some time and consider myself experienced in that regard. However, there is one problem I have been unable to resolve that causes much distress. This problem is accidental uncoupling of the night bag

CHARTER CONTINENCE CARE ISSUE 21

from the leg bag. This causes chaos in the early hours. I fix the connectors as firmly as possible, but still occasionally have a disaster. Could I solve this problem by attaching the night bag directly to the catheter, thus dispensing with the leg bag at night? Or is there a device available to prevent this accidental detachment? I would be grateful for any advice.

Mr C, Gloucestershire Thank you for your letter. Yes, you can connect a non-drainage night bag to your catheter without any adverse effects. You should speak to a continence specialist in your area for help in going about obtaining and fitting the appropriate device ■ This is the third copy of Charter continence care that I have received through caring for my 87-year-old husband, who is now becoming doubly incontinent. Thank you for an interesting magazine, which I now pass on to the surgery where I continue

Address your correspondence to: The Editor,

Charter continence care Hayward Medical Communications 8–10 Dryden Street, London WC2E 9NA email: edit@hayward.co.uk The information provided on this page is not intended to be, nor is it to be treated as, a substitute for professional medical advice relative to a specific medical condition or question. Therefore, the Editor, author, publisher, or any of their respective employees, officers and agents, accept no liability for the consequences of any inaccurate or misleading data, opinion or statement. Always seek the advice of your qualified healthcare professional regarding your medical condition.

to work on a very part-time basis – just to keep my sanity! In your comment at the start of issue 20, you mention passing urine frequently at night. What is the reasoning behind putting on elastic stockings before going to bed? Are these the normal knee-high elastic stockings that my husband wears in the day to prevent leg ulcers (he is wheelchair-bound)? What do the stockings that you mention do? I thought your tip about making the toilet seat and mat a different colour was brilliant and feel that this should be adopted by all NHS hospitals. This tip should be circulated to all continence nurses, because it is so sensible and yet such a basic and easy thing to do. I have recently been coping with my husband’s ‘diarrhoea’, which turned out to be overflow due to constipation caused by codeine-based painkillers he was taking for a tooth infection. There may have been an article on this already, but I would welcome another.

Mrs W (via email) Thank you for your letter. I am pleased that you enjoy reading the journal and that the copy you receive is being helpfully recycled at the doctor’s surgery. I was given the advice about stockings that I included in my comment in issue 20 by a professor who deals with the treatment of older people. Many medications do not help older people and can cause problematic side-effects. The stockings I was recommending are not the thromboembolic deterrrent (TED) stockings, but rather full-length flight support stockings. This helps with the blood flow and circulation through the kidneys and with blood pressure. The person will still have to pass urine once or twice, normally during the first part of the night, but this is rather than three to six times a night. Constipation is a subject that has been raised in previous issues, but I am sure that we will revisit it again in a forthcoming issue of the journal. There are a lot of medications that affect both the bladder and the bowels and it is always good to read the side-effects literature included with any tablets you are taking, as not all doctors will explain these thoroughly ■

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Charter Journal - Continence Care Issue 21