The bladder – your guide to how it works ... page 5
Toilet training children with learning difficulties ... page 12
Issue 24 Spring 2011
continence care
Making the right decision: understanding your options for catheterisation
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Contents
Comment
Back to basics 5
Medical insight How does the bladder work? by Rachel Busuttil Leaver
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Straight talking Helping you understand your options for catheterisation by Ann Winder
Coloplast 11 Discretion just became easier Practical care 12 Toilet training children with learning difficulties – a step-by-step guide by June Rogers
14 Resources Forum 15 Q&A
Cover picture PLAINPICTURE/CULTURA
CHARTER CONTINENCE CARE ISSUE 24
Welcome to a new year – 2011! I hope all of our readers have enjoyed the festive season, and I would like to welcome new readers to this exciting first issue of the year.
Bowel myths debunked There are so many myths about bowel function, and these have resulted in some strange practices. I thought I would share with you those that I have been presented with by patients at clinics: ● ‘I must poo daily or I’ll get piles’ – a middle-aged man ● ‘If I don’t go for two weeks I will die as the bowel will rupture’ – a teacher ● ‘Older people will always have bowel incontinence as they get older’ – a care home manager(!) ● ‘I always had my bowels open every day at the same time when I was younger and in the army. Now I have to take four types of laxative to achieve this’ – an 89year-old man complaining of constant loose stools ● ‘I take many laxatives – over 100 senna a day to stay slim’ – a 16-year-old girl ● ‘I never eat anything green, a root vegetable or fruit’ – a 30-year-old man who weighed 28 stone and suffered from constipation ● ‘I have regular bowel irrigations privately, as this will ensure I don’t get bowel cancer’ – a 38-year-old woman ● ‘I must do manual evacuations of my bowel each day as I have no sensation to pass stools’ – a 30-year-old male with no neurological condition. Bowels are the very last taboo. Many people, young or old, may see it as a disaster when they suffer from urinary incontinence; but when the bowel evacuates without warning, this is beyond embarrassment, causing extreme shame for most people. Cleaning up and changing clothes is almost impossible outside of the home, as public places rarely have showers available. I have noticed a few in service stations and airports, but these are not generally provided – and definitely do not have facilities to dispose of soiled pads or clothes if required. There are a few companies which make containment devices for faecal fluid, but few are designed for comfort, or are easy to change. The large incontinence pad is the most frequently used containment product on offer, but it does not remove the difficulty of changing and disposal, or address issues of comfort and dignity for the wearer. Continued overleaf 3
When providing privacy and dignity for ‘patients’, or sufferers of these problems, it should be the aim of not only health- and social care services, but of councils, to provide some facilities for public use. I appreciate that times are difficult and money tight, but in this day and age, surely some design student could develop a self-cleaning, allencompassing shower–toilet area with a product disposal chute, to be made available in town centres. A RADAR key could be issued so that users felt private and safe. In the meantime, there are some new products and techniques on the market aimed at assisting with bowel management – for example, anal irrigation. If you think something like this might be helpful to you, please ask your nurse specialist or GP for further details.
Proceed with caution It was interesting to see the research about aspirin lowering the risk of bowel cancers in the media. I am sure many people heard this news, as it was in most of the national newspapers last year. My caution with this sort of press is to always check first with your doctor before popping any pills, as doing otherwise could make your individual situation worse.
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 Lead Nurse Continence, Tynemouth Road Health Centre, Tottenham, London Mary Brown RGN BA(Hons) PGCE Continence Nursing Team Manager, NHS Lothian Michael Cogswell Paraplegic, Pluckley, Kent
An expanded readership I am pleased to report that when the Board reviewed the Charter continence care readership last year, we identified so many new readers that we felt it would be useful to go ‘back to basics’. Consequently, Rachel Busuttil Leaver has produced an article describing the workings of the bladder. Other topics covered in this issue include June Rogers’ step-by-step guide to toilet training children with learning difficulties; and for my part, I have contributed an article outlining the different options available to patients considering catheterisation. My thanks go to all the authors for taking the time to write articles over the previous years, and for sharing with our readers their wealth of knowledge. I would also like to thank all those readers who write in to Charter. I hope we manage to help a few of you to receive additional care. Please keep your letters coming in, as we hope to share some of our readers’ experiences with you all in the future. It is always reassuring to find that you are not alone. Ann Winder, Editor The Editor Charter continence care Hayward Medical Communications 8–10 Dryden Street London WC2E 9NA email: edit@hayward.co.uk 4
Rachel Busuttil Leaver MSc 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, Department of Urology, Bristol Royal Infirmary 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. Sales Director Ian Arkless. Managing Editor Robin Jones. Chief Sub Joel Barrick. Senior Sub Editor Anne-Claire Bouzanne. Sub Editor Kirstin Knight. Editorial Assistant Jessica Atkey. Art Editor Richard Seymour. Publications Co-ordinator Hayley Mayes. 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 © 2011 Hayward Group Ltd. All rights reserved. ISSN 1745-9982. Printed by Williams Press Ltd.
CHARTER CONTINENCE CARE ISSUE 24
Medical insight
How does the bladder work? Many take their urinary system for granted, but it is a complex area of the body. Rachel Busuttil Leaver explores the bladder’s important role in everyday life For most people, the bladder is one of those body organs that is easy to ignore; they are usually only reminded of its existence when they need to go to the lavatory and pass urine, normally once every few hours. Most of the rest of the time the bladder silently and painlessly goes about its business, filling up with urine until it is time to empty again. However, it is also true that when there is a problem with the bladder it can affect all aspects of a person’s life; then it becomes very difficult, if not impossible, to ignore.
The bladder is a hollow sac-like organ that lies in the pelvis behind the pubic bone, and is connected to the outside of the body by a narrow tube called the urethra. Below the bladder is the pelvic floor, which is made up of muscles and ligaments, forming a sling-like support for the organs of the lower pelvis.1 The urethra passes through the pelvic floor.
Rachel Busuttil Leaver MSc BSc(Hons) RN PGCE Lecturer Practitioner in Urological Nursing, London South Bank University and University College London Hospitals
The bladder The bladder is a triangular empty sac, with the widest part at the top, and the narrow end at the bottom, where it connects to the urethra. Just above this is an area known as the trigone. The ureters open into the bladder at the trigone. The area below the trigone is called the bladder neck.
The upper and lower urinary tract The bladder is part of what is known as the urinary tract, which is divided into the upper and lower urinary tract. The upper tract consists of the two kidneys, which lie in the lower back and are attached to the bladder by narrow tubes called ureters. These are also part of the upper urinary tract. The lower urinary tract is made up of the bladder, bladder neck, urethral sphincters and the urethra.
Differences between men and women In a woman, the vagina lies between the bladder and back passage (rectum) (see Figure 1), while in a man, the rectum runs along the back of the bladder (see Figure 2). Like the urethra, these passages pass through the pelvic floor and are supported by its muscles. In women, the urethra is short (3–5 cm) and Figure 1. Female bladder and pelvic organs
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Kidney Uterus (womb)
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•
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Pubic bone
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Back passage (rectum)
Vagina
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Spine
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Pelvic floor muscles
Urethra Vagina
CHARTER CONTINENCE CARE ISSUE 24
Urethra
SOURCE: PATIENT PICTURES – BLADDER DISORDERS. HEALTH PRESS, OXFORD
Urethral sphincter
Bladder
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Medical insight
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Kidney
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Ureter Prostate
Prostate
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Spine
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SOURCE: PATIENT PICTURES – BLADDER DISORDERS. HEALTH PRESS, OXFORD
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Bladder
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Pubic bone
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Urethra
Figure 2. Male bladder and pelvic organs
Back passage (rectum)
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Pelvic floor muscles
straight, and opens outside the bladder between the clitoris and the vagina. The male urethra is much longer, at approximately 17 cm, and is S-shaped. The area around the bladder neck appears to be different in men and women. In men, a circular ring of smooth muscle surrounds the bladder neck. This extends down into the prostate along the urethra, together with some muscle fibres that lie lengthways (longitudinally) and continue down into the pelvic floor. This area is known as the external sphincter. In women, there is no circular layer of smooth muscle around the bladder neck. Instead, there are smooth longitudinal muscles that lie along the length of the urethra. These sphincter areas in both men and women are responsible for keeping them dry, and are supported by the pelvic floor muscles.1,2
Urethra
Urethral sphincter
Brain (master control centre)
Cerebral cortex Pons (pontine micturition centre)
Spinal cord
Sacral cord (sacral micturition centre)
How the bladder works The bladder is made up of layers. The innermost layer is arranged in folds, which allow the bladder to stretch and expand as it fills with urine. The muscle layer of the bladder (detrusor) is involved with bladder filling and emptying. It is made up of muscle fibres, which are arranged to form a mesh, rather like a net. This muscle contains stretch receptors – special areas that respond when the bladder wall stretches as it begins to fill with urine.2 The trigone area does not expand, but contains many stretch receptors, making it a very sensitive area.
The nervous system All the stretch receptors from the bladder layers are connected to nerves. These nerves then travel up the spine to the brain. There are three main areas of the body that control bladder filling and emptying: the spinal area, which, naturally, is in the spine; and the areas of the brain
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Figure 3. How nerve pathways control the filling and emptying of the bladder
known as the cerebral cortex and the pontine (see Figure 3). Messages from the bladder travel to the spine via nerves, before continuing on up to the brain. The cerebral cortex receives these messages and uses them to decide whether it is a convenient time to empty the bladder or not. The messages travel along nerves in the body by means of a wave of electrical current, and are controlled by the pontine centre, which acts like an on/off switch. When these messages reach the muscle fibres in the
CHARTER CONTINENCE CARE ISSUE 24
Medical insight
Ureters
Bladder neck External urethral sphincter
Urethra
Figure 4. Emptying of the bladder. As the detrusor relaxes, the bladder neck lowers and opens, and urine is released. Once the bladder is empty, the external sphincter and bladder neck close and the bladder begins to fill up again
bladder, they move from nerve to muscle via chemicals known as neurotransmitters. An example of one such transmitter is called acetylcholine. This crosses over to the muscle, causing it to contract. Once it stops crossing over, the muscle relaxes.2
Filling and emptying the bladder Urine is made up of water and dissolved waste products that have been filtered out of the blood by the kidneys. It is formed in the kidneys at the rate of about 30 ml an hour. Most people make approximately 1,500 ml of urine a day, although the more a person drinks, the more urine they will produce. A number of waste products are produced daily in the body; one is urea, which occurs as a result of the breakdown of protein (from food such as meat) by the liver. If waste products are left to build up in the blood and in the body, they can cause health problems and, in some cases, even death. The kidneys are, therefore, crucial for getting rid of the waste and keeping the body functioning properly.2 A malfunctioning bladder may affect the function of the kidneys, and so it is important to ensure that anything done to the bladder will not cause harm to the kidneys. Most people get the first urge to pass urine when there is about 200 ml (around a cup) of urine in the bladder. They can usually put off emptying the bladder at this stage, however, and so it continues to fill and stretch. A normal bladder holds around 300–400 ml. Most people pass urine between four and six times a day, and sleep through the night.
Passing urine The urine travels down the ureters into the bladder, causing the bladder to stretch. Stretch receptors send messages up the spine to the brain, and the cerebral
CHARTER CONTINENCE CARE ISSUE 24
JACOPIN/SCIENCE PHOTO LIBRARY
Detrusor
cortex sends a message back, stopping the bladder muscle from contracting and allowing it to relax so the bladder continues to fill. There are also nerves from the pelvis to the sphincter and pelvic floor, to ensure that the pelvic floor lifts up and the sphincters close so that no urine leaks out. When the bladder is full, the message gets to the brain; if it is convenient for the person to pass urine, the message is sent back via the pontine centre and down the spine to the bladder. This causes the bladder to contract, the pelvic floor and bladder neck to lower, and the sphincter to relax. Urine is then pushed out of the bladder. Once the bladder is empty, the process is reversed: the sphincter and bladder neck are closed and the pelvic floor is lifted, while the bladder relaxes and filling begins again (see Figure 4). We are not usually really aware of the process of filling and emptying the bladder as this happens unconsciously (in other words, it is not under our control). However, we are able to control when to start and stop passing urine. When the first urge of needing to pass urine is felt, most people react by squeezing the muscles around the bottom of the bladder. What this actually does is squeeze the sphincter muscles tight shut, lifting the muscles of the pelvic floor so that no urine leaks out. When it is a convenient time to pass urine, the pelvic floor and bladder neck are lowered as the person relaxes, and the sphincter opens, allowing urine out of the bladder. Passing urine, therefore, involves both voluntary and involuntary actions, and a complex nerve pathway to co-ordinate those actions.1,2 The lower urinary system is more complicated than it may first appear to someone who is unaware of the many different layers, muscles and nerves that make up all its parts. Understanding the complex workings of the normal bladder is a good starting point in helping to understand how and why things can go wrong, and what can be done to put them right ■ References 1. Getliffe K, Dolman M. Promoting continence: A clinical and research resource, 3rd edn. Oxford: Baillière Tindall, 2007. 2. Marieb E. Human Anatomy and Physiology, 6th edn. Harlow: Benjamin Cummings, 2003.
Key points ● The bladder is only one part of the complex urinary system. ● The folds in the inner lining of the bladder allow it to stretch as it fills with urine. ● Sensitive areas in the bladder muscle wall are triggered when it stretches, sending out messages via nerves. ● Nerves in the spine and the brain control bladder emptying. ● Bladder emptying happens as a result of both voluntary and involuntary mechanisms.
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Straight talking
PLAINPICTURE/CULTURA
Patients should be fully involved in any decision regarding a catheter
Helping you understand your options for catheterisation Patients need to be more reliably informed of the alternatives when it comes to catheterisation. Ann Winder examines the issues that should be addressed
Ann Winder RN Senior Continence Specialist, Park Drive Health Centre, Baldock
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In clinical practice, rarely a day goes by when a continence specialist is not contacted by a front-line worker regarding one of their patients who has a problem with an indwelling urethral or suprapubic catheter. As a clinician, my first question is always, ‘Why was the patient given a catheter in the first place?’ More often than not, the reply is, ‘I don’t know. They went to hospital and returned catheterised’. Likewise, when I make home visits to patients with problems, they are often unclear as to why they were catheterised – except if the reason was to do with retention (not being able to pass urine) or incontinence. Every year, over one million urinary catheters are inserted into patients in NHS hospitals. This practice is not new, and catheters have been used for over 100 years with very little change in their design. They
are obtrusive, not always comfortable, and can frequently lead to health risks for patients. Nurses and doctors are so used to catheters it has become common practice to catheterise, but this does not mean it is always appropriate. The practice is so widespread that professionals do not always appreciate the dangers of the process, or the importance of effective evidence-based practice. This article does not attempt to give nurses the information to evaluate the needs and correct care of a catheterised bladder, but rather to offer you, the patient, some guidance and knowledge, empowering you to understand your role in the decision-making process when considering whether or not to have a catheter inserted. There are times, in an emergency situation, when the only safe way to manage a bladder problem is to insert a catheter; however, this
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article considers only those patients who have to decide whether they wish to continue with a long-term indwelling urinary catheter for the management of their bladder problems. The article will explain the urethral (see Figure 1) and suprapubic (see Figure 2) routes of catheterisation for a chronic or long-standing bladder problem. Intermittent self-catheterisation (ISC) is well documented, and is recognised as the gold standard for managing bladder problems associated with retention. If you suffer from non-voiding retention, you are unable to pass urine at all, whereas if you suffer from partial retention, it is possible to pass urine, but some residual urine is left in the bladder. ISC may not be possible due to your overall condition or other external influences; in these cases, urethral or suprapubic catheters are the only resort. The problems and benefits of ISC will be discussed in future articles.
SCIENCE FACTION/SUPERSTOCK
Straight talking
Figure 1. A two-way urinary catheter
In the community, outside of the hospital setting, the main reasons for urinary catheterisation are: ● To monitor urine output, and check if the patient is having enough fluids or is becoming dehydrated ● To bypass an obstruction – either a narrowing of the urethra (called a urethral stricture) or, in men, an enlarged prostate gland – that is restricting the flow of urine and causing overflow retention (a condition where the bladder is constantly dribbling, or continues to dribble for some time after you have passed urine) ● To address neurological problems resulting in retention or overflow retention, with or without incontinence (for example, multiple sclerosis, spinal trauma, or diabetes) ● To assist with dignity and comfort in palliative care, if appropriate, in the last stages of life ● To manage incontinence when all other methods have failed, or to assist with dignity, privacy and comfort for social reasons. You and/or your relative or carer must be central to the decision-making process in judging whether catheterisation is suitable, and you must be able to make an informed decision using all the knowledge available. If you are medically unable to do this, an advocate, relative or carer must take that responsibility. The healthcare professional must guide those making the decision, without pressurising them. Unfortunately, due to staff shortages and relative time pressure, patients are often encouraged to have a catheter inserted. It is thought that healthcare workers promote catheterisation because, in part, catheter care is easier than changing a wet bed or clothing, or toileting a less mobile patient on a frequent basis. There is also the cost element, as disposable pads are expensive; in some areas of the country, patients have to purchase their own products, or top up the supplies they receive from the NHS using their own money.
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MEDICIMAGE/PHOTOLIBRARY
Reasons for long-term catheterisation
Figure 2. Suprapubic catheters require an artificial opening to be created between the bladder and the anterior abdominal wall, so that the catheter can reach the bladder
However, long-term indwelling catheters nearly always create problems for the patient, and can result in health issues, which are discussed below.
Associated medical risks A catheter is not a cure-all solution. It can pose some serious risks to patients, including: ● Trauma to the urethra ● Long-term bladder function problems – if on free drainage, the bladder will lose its tone and capacity ● Potential cancer-causing (carcinogenic) changes in the bladder ● Possible bladder stone formation ● Trauma to the urethra in both male and female patients ● Death of skin tissue (necrosis) around the area above and behind the pubic bone (the suprapubic site) ● Carcinogenic changes around the suprapubic site and in the underlying tissues ● Allergic reactions to the products ● A rising risk of catching infections the longer the catheter is left in place. Between 487 and 1,161 patients die each year as a result of catheterrelated infections. Urine infections can cause a delay in recovery, and treating the infections
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Straight talking creates the possibility of the patient becoming antibiotic-resistant. If any of these risks worry you, speak to your healthcare professional about your concerns. You and/or your carer should make a list of questions and answers to assist with your individualised catheter management programme (see Boxes 1 and 2). These must be updated each time a catheter is changed.
Catheter valves Having a catheter does not mean you need to be connected up to various drainage bags, strapped to the leg or draped over bedsides for all to see. A catheter valve can help you to live a more comfortable life, and could reduce the amount of time spent in hospital (although a healthcare professional needs to assess your suitability before you can use a valve). Benefits include: ● Supporting the natural function of the bladder by helping flush out all the debris in the urine in a normal way, reducing the catheter blockages ● Reducing the damage and irritation to the bladder lining (mucosa) ● Reducing the necrosis of the mucosa ● Reducing the weight of urine bags causing pressure (traction) on the bladder neck ● Increasing patients’ options and satisfaction ● Reducing costs ● Improving quality of life ● Providing a more comfortable and discreet ‘natural’ method of bladder emptying.
Summary Urinary catheters are so common within the healthcare setting that staff may often think they are a normal part of caring for the elderly or those with a disability or incontinence, rather than a potentially dangerous and invasive device. Frequently, patients and/or their advocates do not fully understand the reasons for catheterisation or the associated risks, preventing them from making an
Key points ● Catheterisation is common, but it is not always necessary, and can pose health risks to the patient. ● The decision to have a catheter inserted should be made together with the patient and/or their carer, not by the healthcare professional alone. ● Long-term indwelling catheters can cause infection, trauma and bladder function problems. ● Catheter valves can improve a patient’s quality of life and reduce costs, as well as lowering the risk of irritation and tissue damage.
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Box 1. Questions to ask when thinking about catheterisation Patients, carers and healthcare workers need to ask several questions before opting for a catheter. • Why is the catheter necessary? • Whose decision is it to insert the catheter? • Who will change the catheter and when? (Patients can be taught to change their own catheters where appropriate and with consent) • Who is responsible for planning the care? • Who is responsible for ensuring the appropriate care is given? • Is there a plan for removing the catheter? • Culture and religious practice can affect catheter care – would fasting cause catheter problems? • Can intercourse be performed with a catheter in place? (Men and women can be taught to change their own catheters, which ensures privacy)
Box 2. Issues to consider once you have made your decision Patients, carers and healthcare workers need to consider a number of issues, including: • The size and make of the catheter to be used • Whether each catheter used is documented to include the manufacturer’s codes • Whether any problems at catheter changes are documented – for example, debris in the tube or discomfort on removal • Any changes in urine – that is, in colour, blood or pH levels (using dipstick test if required) • Fluid and diet intake, swallowing difficulties and so on • Whether constipation is a problem • Whether any other medication could affect catheter drainage or bladder function • Attachments – urine bags, catheter valves, leg straps, bag holders • What to do in the case of an emergency (such as a nondraining catheter, or the catheter being expelled) and relevant 24-hour contact numbers informed decision. The documentation and management programmes that every patient with an indwelling catheter should have are often found to be lacking in details, or not to exist at all. Patients are rarely given a choice in the types of appliances and equipment they can use, such as leg drainage or body-worn bags, valves and attachment straps. The reviews carried out when a catheter is changed are also lacking in the details that would enhance the care programme and offer patients more security and confidence in managing their own care. In some areas, patients are taught to change their own indwelling catheters very successfully, giving them privacy and dignity, as well as relieving primary care staff of routine catheter changes. Empowering the patient, and working together with the healthcare professional, creates a partnership that is beneficial to both parties, and which should be encouraged ■
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Discretion just became easier Bulky, indiscreet and difficult to dispose of – sometimes traditional catheters can be a nuisance. Thankfully, Coloplast has hit upon a solution: SpeediCath Compact Male At present, male catheters can prove difficult to conceal, awkward to store and carry, and inconvenient to dispose of. After listening to feedback from male catheter users, Coloplast has recognised that greater discretion has long been their priority. At last, there is a catheter solution for men that’s sleek, compact and ready to use. SpeediCath® Compact Male is now available, and offers a number of advantages over traditional catheters: not only is it more convenient to store, and easier to carry and dispose of – it ‘It allows provides you with increased me much hygiene and control.1,2 more SpeediCath Compact freedom!’ Male is as safe and efficient Mr S as regular SpeediCath. Even better, it allows you to benefit from its discretion in all areas of your everyday life – at work, in the home, and when out and about!
Travelling just got easier with SpeediCath Compact Male
much room in a suitcase or hand luggage – can be a challenge. However, Coloplast has listened to their concerns, and has been working on a solution that finally meets the needs of male catheter users. For a smooth journey through Customs, and to avoid any embarrassing questions at the airport, remember to carry the Coloplast Travel Certificate with you. This explains what you’re carrying and why you’re carrying it. If you’re stopped by anyone at the airport, you can simply hand the certificate over to the ‘It fits airport staff and let it do the explaining for well in my you! For your free Coloplast Travel pocket, and is Certificate, please call 0800 220 622. discreet and For more information and a sample of SpeediCath Compact Male, contact Charter hygienic!’ Healthcare on 0800 220 622 quoting reference Mr P CHARTER 24 ■
When travelling, there never seems to be enough space in your suitcase to take your clothes along with you – never mind your essentials, like intermittent catheters and other continence products. Intermittent compact catheters for women – for example, the SpeediCath Compact – have been available for years now. Many people have benefited from the space-saving, discreet nature of these products – not to mention the fact that they are barely recognisable as medical equipment. For men, however, finding a catheter that can be discreetly carried – and which does not take up too
CHARTER CONTINENCE CARE ISSUE 24
‘Easy to carry about, use and dispose of!’ Mr K
References 1. Chartier-Kastler et al. Safety of a new compact catheter for men with neurogenic bladder dysfunction: a randomised, cross-over, open-labelled study (submitted to Spinal Cord). 2. Bagi et al. Safety of a new compact male intermittent catheter: a randomised, cross-over, single blind study in healthy male volunteers. Urologia Internationalis (in press).
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Practical care
Toilet training children with learning difficulties – a step-by-step guide Toilet training children with learning difficulties, although sometimes challenging, is easily achievable. Here, June Rogers introduces the ‘one step at a time’ programme
June Rogers MBE RN RSCN BSc(Hons) MSc ENB 978 ENB NO1 ENB 216 PromoCon Team
Director, Manchester
All parents look forward to their children being toilet trained, but for some parents of children with special needs, this milestone can seem unobtainable. However, experience has taught us that, for many children, becoming toilet trained is an achievable goal. Most normally developing children become clean and dry during the day between two and four years of age; however, there is evidence of a trend towards later toilet training among the general childhood population within the UK. Sixty years ago, toilet training was usually started at around 18 months of age, whereas nowadays, the usual age to start is around 28 months. There are a number of theories regarding this, with the transition from cloth to disposable nappies and more mothers going out to work being among the probable causes.
Child-centred approaches In the 1960s, there was a trend towards a ‘child-centred’ approach to toilet training, where the family would wait to begin until the child showed an interest. This approach worked well when children wore cloth nappies, as the mother was able to identify quite early on when the child was developing bladder maturity, from dryness after naps and increasing time between voids. Also, the child had the opportunity to learn to recognise the consequence of full bladder signals by feeling very wet! These factors were often the ‘triggers’ that led to the initiation of toilet training. Unfortunately, the ‘wait until the child is ready’ approach persists today, despite the fact that most children wear disposable nappies. Many of the factors that would trigger the family to start toilet training are no longer evident. Consequently, when parents are asked why they have not started to toilet train their three-year-old, they say they do not think
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he or she is ready – and from a child’s point of view, why would you want to stop wearing your nice, comfortable, portable toilet that is so convenient to use!
Toilet training and children with learning difficulties Although many are now starting nursery in nappies or pull-ups, normally developing children suss out after a few weeks that they need to be using the toilet like everyone else, and they very quickly become fully toilet trained. For children with learning difficulties, however, the child’s lack of interest often results in a delay to the initiation of toilet training until the child ‘appears ready’. Unfortunately, with some children, if we waited until they appeared ready, we would be waiting a very long time! As a result, clinical experience has shown us that we need to take a different approach to toilet training children with learning difficulties than is usual with normally developing children. Becoming toilet trained is the interaction of two main processes: physiological maturation of the bladder and bowel, and social and cultural awareness. For children with learning difficulties, it is often their lack of social awareness that results in delayed toilet training, rather than an inherent problem within the bladder or bowel. Therefore, rather than waiting for the child with learning difficulties to become socially aware and motivated before toilet training commences, we use the maturation of the bladder and bowel as the trigger factor for starting training. The social awareness and motivational aspect we add in as part of a behavioural programme involving lots of positive reinforcement.
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Practical care ■ ERIC
Has a range of resources available to purchase to help with toilet training Phone: 0845 370 8008 Website: www.eric.org.uk ■ PromoCon
PromoCon provides impartial advice and information regarding childhood continence issues including toileting problems, products and services Helpline: 0161 834 2001 Website: www.promocon.co.uk ■ ‘One step at a time’ is available to download free from www.continencevictoria.org.au or on a CD (small charge for P&P) from PromoCon: 0161 834 2001
‘One step at a time’ Toilet training is a skill that can be broken down into steps and, by addressing one step at a time, the whole process can be made a lot easier for the family. Putting children on a toilet skill development programme enables them to learn the skills they need to become toilet trained. Once those skills are in place, more formal training – involving removal of the daytime nappy and scheduled sitting on the potty or toilet – can begin. ‘One step at a time’ is an approach that has been used successfully in children with a whole range of learning difficulties, with each step bringing the child closer to the ultimate goal of becoming toilet trained.
Step one: setting the scene This involves introducing and encouraging changes to the routine of nappy changing that enable the child to learn new skills and start on the path towards toilet training. It includes establishing healthy habits as regards eating and drinking, and sitting on the potty or toilet at regular intervals during the day. Changing the child in the bathroom enables them to become more aware of the connection between urine and faeces and the toilet. For those children who are able to stand unsupported, we also suggest the child is changed standing up, as that way they can get more involved with the process. Learning about wet and dry is also introduced during this time.
Step two: developing the skills needed This step focuses on skills like sitting on the toilet, pulling pants up and down, and knowing what the toilet is for; it includes flushing, and washing and drying hands.
Step three: raising awareness This step involves identifying the child’s habits, such as how long they can stay dry for, and if there is a regular time when they open their bowels. Once it has become clear that the child is able to stay dry for increasing periods, we would move the child towards coming out of disposable products and into normal washable underwear or training pants. However, we would suggest that they need to be able to stay dry for at least one and a
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half hours, if not longer, and have no underlying problem with their bowels, such as constipation.
Step four: using the toilet By now, we expect urination and defecation to start happening in the toilet. Having practised the necessary skills, we would expect the child to co-operate when taken to the toilet, and sit on the toilet and attempt to pull their pants up and down. The skills introduced and developed at this stage include using the toilet for urine and faeces, bottom wiping and using unfamiliar toilets.
Step five: night-time control Once dry during the day, some children will spontaneously become dry at night within a few months, if not sooner. However, a number of children may persist with bedwetting (nocturnal enuresis) for some time. Most children will be dry at night by the time they are five or six years old, but we know that for some children, bedwetting persists beyond this age. The families of these children need to be aware that bedwetting is a treatable condition, and should seek help to correct the problem, rather than just leaving the child in nappies.
Final considerations The duration and overall success of toilet training will depend very much on the child’s individual ability, and so will vary accordingly. Also, there will be some children who will always require additional support to use the toilet, or need the occasional prompt to go, particularly if they are busy or distracted. Once toilet training begins, it is important that everyone involved with the child – both at home and school – is aware of the programme, so that a consistent approach might be maintained. Both families and healthcare professionals should remember that up to 30% of children can have a wetting and/or soiling problem at any one time. These problems can include constipation, nocturnal enuresis, or daytime wetting associated with underlying pathology. All of these conditions need to be treated appropriately. For any child with learning difficulties who presents with wetting and/or soiling, there should not be a presumption that the problem is due purely to a delay in toilet training or a ‘behavioural’ problem. Rather, all children, including those with special needs, should undergo a holistic continence assessment not only to exclude any underlying pathology, but also to give a correct diagnosis of the problem and help inform the direction of the toilet training programme ■
Key points ● Toilet training children with learning difficulties is an achievable goal. ● ‘One step at a time’ is a programme that can make the process of toilet training easier for the family.
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Resources ■ The Prostate
Prostate cancer is the most prevalent cancer among men in the UK, with 36,000 men being diagnosed every year. The Prostate Cancer Charity is the UK’s leading charity working with people affected by prostate cancer. We fund research, provide support and information, and campaign to improve the lives of men who suffer from prostate cancer. Treatments for prostate cancer, such as surgery and radiotherapy, can cause urinary side-effects, including leakage, stress incontinence, urgency, frequency and retention. Our fact sheet ‘Urinary problems and prostate cancer’ provides information about different ways of treating or managing these problems. This is part of the
‘Tool kit’, a resource designed for men who have been diagnosed with prostate cancer. Like all of our other publications, this is free, evidencebased, and independently reviewed by health professionals. All resources can be downloaded from our website or ordered via the helpline. We also provide the only nationwide telephone and email service dedicated to prostate cancer. You can talk to one of our specialist nurses via our confidential helpline, which is open from Monday to Friday between 10 am and 4 pm, with extended hours on Wednesdays between 7 pm and 10 pm. Helpline: 0800 074 8383. website: www.prostate-cancer.org.uk
■ Diabetes UK
Diabetes UK is the leading charity for the over 3.5 million people in the UK with diabetes. In the UK, there are currently 2.8 million people diagnosed with diabetes; however, it is estimated that 850,000 people have type 2 diabetes, but do not realise it. If left untreated, or managed badly, diabetes can lead to a variety of serious complications, including heart disease, stroke and blindness. Urinary incontinence refers to the inability to hold urine in the bladder. It occurs when the muscles and nerves associated with the bladder are unable to hold or appropriately release urine. Diabetes sufferers have a tendency to experience these problems. Causes can include: • Hyperglycaemia (high blood glucose levels), which causes thirst and increases urination • Urinary tract infections
• Physical changes in bladder muscles (for example, after the menopause) • Enlarged prostate gland • Damage to nerves caused by other conditions, such as multiple sclerosis or diabetic neuropathy. There are a number of treatments and interventions available depending on the type of incontinence, ranging from pelvic floor exercises to medication. Weight loss (if appropriate) and improved diabetes control can help too. For more information on diabetes and incontinence you can visit our website. Alternatively, the Diabetes UK Careline operates from Monday to Friday between 9 am and 5 pm, and offers information on any aspect of managing the condition. Helpline: 0845 120 2960. website: www.diabetes.org.uk
■ Alzheimer’s
Dementia is an umbrella term used to describe a range of different conditions, all of which have in common a gradual loss of brain function. Alzheimer’s Society is the leading charity supporting people with dementia and their carers, with services all around the country, and over 5,000 staff and volunteers. Incontinence is a common symptom of dementia, and one which progresses as the disease does. Sometimes, people with dementia may experience confusion when it comes to using the toilet. They may feel embarrassed, and try to hide this from their families. When incontinence adds to other emotional and physical issues, it can lead to complicated feelings.
As time goes on, a higher level of supervision may be needed to prompt people with dementia to use the toilet, and incontinence pads may become necessary. However, there is support available – a community care assessment made by the social services is a good start. Alzheimer’s Society’s factsheet ‘Coping with incontinence’ is an excellent resource, and can be ordered by calling 01628 529 249, or downloaded from our website. Further information and support can be obtained via the National Dementia Helpline, which operates from 8.30 am to 6.30 pm, Monday to Friday. Helpline: 0845 300 0336. website: www.alzheimers.org.uk
Cancer Charity
Society
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Forum
In conversation with …
This is a very interesting letter and I would be keen to hear from other readers who have had a similar experience ■
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
Could you please give me some information on indwelling catheterisation? My husband has been wearing a long-term catheter since October 2009, when he was diagnosed with urine retention and acute renal failure. I have read the article on intermittent catheterisation, and I am anxious to know more on the subject.
Ann Winder RN Senior Continence Specialist, Park Drive Health Centre, Baldock
I have a rare neurological condition known as generalised dystonia. This means that my muscles don’t contract or relax at appropriate times. It affects almost solely the voluntary skeletal muscles, although unusually, I have developed it in my bladder over the last five years. I have extremely low bladder pressure, but as dystonia causes great fluctuation in muscle tone, there have been occasions when sudden high pressure has caused me to be incontinent. While this is rare, I need to wear continence pads every day, as the muscle tone changes are sudden. Last year, my primary care trust (PCT) changed its continence products. I reacted badly, initially developing a rash, and then constant itching. Since then, I have had three appointments at a major London hospital where I have seen one of Europe’s leading consultants in complex urogynaecological cases of a neurological origin. The appointments included a full urodynamics examination. I also had another five-hour urodynamics investigation. After this, I had a cystoscopy at my local hospital. During this period I also had a routine smear test. On these occasions when it was necessary to be physically examined, I mentioned my discomfort with the new products; each time I was told to speak to the PCT continence service. I was told that I had to go and ‘be physically examined’ by one of the trained nurses. I stated that I felt that this was not only unnecessary in view of the fact that I had shared my concerns with all the above
CHARTER CONTINENCE CARE ISSUE 24
professionals at times when I needed to be examined for genuine medical purposes, but that they were adding to a lack of dignity. Lying like a baby so a nurse can see ‘nappy rash’? No way. I feel defiled by such comments. I tried writing to the head of continence services, who suggested that as I ‘was reluctant’ to be examined, they could not offer alternative products. When I phoned the continence service to suggest that this may be a matter of interest to Charter continence care readers, I received a letter within 24 hours from the manager stating that, ‘In no way am I implying that we can do more than our medical colleagues for your bladder problems, but continence management is a specialist area of care and all our nurses have a high level of knowledge, skills and academic qualification in this field’. I wonder if anyone else has had the problem of replacement products to which they are allergic, and been told that other products cannot be supplied.
Mrs N (via email)
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.
Mrs S, Glasgow It is important that you seek advice from your husband’s renal consultant, as without his specific medical history it would be negligent to give you advice. However, it is known that intermittent catheterisation is safer than indwelling catheterisation in respect of infection levels. It is also beneficial to maintain bladder drainage intermittently, so again, intermittent catheterisation would enhance this practice. Do get in touch if you need further advice. My article ‘Helping you understand your options for catheterisation’ might be useful ■ I always read your magazine with great interest and hope that one day someone may write in with the same condition as me. Although I am slim, my stomach becomes huge as the day wears on, and I find it very difficult to pass urine. I was referred to a consultant urologist who told me I had an atonic bladder with retention, and nothing could be done other than using a catheter during the day. I cope well using the catheter, but at night it is a completely different story. I have to get up so many times to ‘spend a penny’ that it seems years since I had a good night’s sleep. I take an antibiotic daily, but have developed a water infection that is proving difficult to clear. The two consultants I’ve seen are both of the same opinion – nothing can be done for this condition, which I believe is rather unusual. Is there anyone out there like me?
Mrs B, Leicester Thank you for your letter. I would encourage anyone with similar problems to write to me and share their experiences ■
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