Charter 18 Journal

Can stem cells end incontinence ? ‌ page 7

Coping with male pelvic floor problems ... page 11

Issue 18 Summer 2009

continence care

Moving forward How nurse-led clinics can help you today

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Martin, 35, catheter user

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“ It’s never easy, but it just got easier”

Contents

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Practical care How nurse-led clinics can help you

by Deborah Rigby

7

Medical insight Can stem cells end incontinence?

by Helen Bolton

9

Coloplast My best-kept secret

by Tara Willson

Psychological issues 10 Depression and incontinence

by Jennifer Leddy Straight talking 11 Male pelvic floor problems

by Grace Dorey 14 Resources Forum 15 Q&A

Comment

The Cinderella of the health service Welcome to all new readers. I do hope you find some help from the articles inside this issue. I encourage all readers to share their experiences and the coping methods that they have used to manage their problems.

As a professional, I realise how much I have learnt from my patients over the years, which I can now pass onto others.

Searching for the positives I have been trying to think of some positive news to cheer us all up, as I am writing this following the MP expenses crisis. I am soon to participate in an In 1980, I had all-party meeting in to make the parliament. The good news is that the aim of sheath appliances the meeting is to get two for most of my parliamentary questions male patients raised in the House of Commons about aspects of continence care and provision. This is a very positive move to raise the continence profile, help secure change, and hopefully provide investment in care.

I feel there still remains a lot to achieve to ensure that the care for those with bladder and bowel problems continues to improve. However, we must not forget that we have come a very long way in the past 20 or 30 years.

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Significant progress In 1980, I had to make the sheath appliances for most of my male patients, as there was not the high-quality range available that there is today. There were very few pads on the market and those that were on offer were really only wads of paper. Medication was ineffective, books were few and far between, and there was no information available for sufferers of urinary leakage.

Today there are many products for all conditions – yes, some still do not meet everyone’s individual needs (for example, there is still very little available for women despite the high prevalence of urinary leakage in females), but the industry still strives to improve.

Cover picture IMAGE SOURCE/GETTY IMAGES

CHARTER CONTINENCE CARE ISSUE 18

Continued overleaf 3

No after-dinner speeches The universities and researchers continue to strive to solve the issues, but we are a long way off all problems being cured. Knowledge has grown, but there still needs to be more research and development towards ‘cures’ for these conditions, as at present we only treat the symptoms.

Continence is still the ‘Cinderella’ of health service provision, however. It costs the NHS more than most other conditions, such as diabetes. Unfortunately, continence is not a subject people are prepared to stand up for – it is not really a subject for an after-dinner talk! Who wants to admit in public to having incontinence?

There is a higher prevalence of incontinence in the older population, but only because they cannot hide the problem or have other conditions that exacerbate their bladder or bowel issues. Maybe it is time to write to your local MP (if there are any left!) and raise the profile of these conditions.

In this issue, I am sure you will find the articles as stimulating as I have. Men went to the moon in 1969 and I thought that was remarkable; just 40 years on, to read Helen Bolton’s article on stem cells I find fascinating. How far we have come in such a short time. Deborah Rigby has provided a good article on what to expect from a continence clinic appointment. I still receive calls from patients who are concerned about their appointments and often ask: ‘What will I have to do?’ and ‘Why do I need to fill in the forms?’ Deborah has given a very good explanation as to why the forms are so useful for the clinicians and I hope this will relieve some of the apprehension felt by those soon to attend appointments.

Grace Storey, once again, has offered clear instructions to men regarding the importance of their pelvic floor muscles. Many men still say they do not even know they have a pelvic floor! Where would men be without their champion? Jennifer Leddy’s article is really important, as so many people suffer from depression and when they have a bladder or bowel problem this can either be the cause of their depression or exacerbate their mental state.

Do people always understand the signs of depression? I really thank Jennifer for her insight into this problem.

Thanks to all our authors, and to those who have kindly been writing to me. I apologise for any delays in replying, but the day job has been keeping me very busy just lately.

Ann Winder, Editor The Editor Charter continence care Hayward Medical Communications 8–10 Dryden Street London WC2E 9NA Tel: 020 7240 4493 email: edit@hayward.co.uk 4

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. Senior Sub Editor Joel Barrick.

Sub Editor Christian Bell. Editorial Assistant Claire Robertson.

Art Editor Richard Seymour. Art Director Andrina de Paiva. Publisher Douglas Wright.

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 © 2009 Hayward Group Ltd. All rights reserved. ISSN 1745-9982.

Printed by Turners.

CHARTER CONTINENCE CARE ISSUE 18

Practical care

IMAGE SOURCE/GETTY IMAGES

Most continence services are available to men and women of all ages

How nurse-led clinics can help you UK continence services follow many different models, but nurse-led clinics often provide the best results. Deborah Rigby explains how, and why, this is the case The value of nurse-led clinics has been discussed by professionals and there is much written on the value of local clinics offering a co-ordinated approach to care. Continence clinics aim to: ● Promote continence and maximise quality of life for people with incontinence ● Increase awareness and offer a skilled assessment of need ● Advise on the promotion of continence and management of incontinence ● Reduce the incidence of incontinence among the population ● Reduce the need for containment in the future (therefore reducing personal and NHS costs).

It has been suggested that nurse-led services result in reduced symptoms of incontinence (frequency, urgency and needing to go to the toilet at night [nocturia]) at three and six months.1 Satisfaction with nurse-led services is high, because nurses tend to spend more time with patients. Moore et al compared the costs of people treated by nurse continence advisers and

CHARTER CONTINENCE CARE ISSUE 18

urogynaecologists and found lower costs arose from treatment provided by nurses.2 Behavioural and lifestyle counselling have been found to reduce symptoms and, when provided by nurses who are trained in

Deborah Rigby MSc Continence Service Manager, Bristol South and West Primary Care Trust

RGN FEATC

Did you know?

There are four main types of incontinence: stress urinary incontinence (pelvic floor weakness); urge urinary incontinence; and difficulty emptying the bladder or bowel ■ Five per cent of girls under 15 years old may have urinary incontinence ■ One in five of the mobile, active, elderly population have continence difficulties and their quality of life is affected ■ Forty to fifty per cent of the elderly in nursing/residential homes have incontinence ■ Forty-two per cent of incontinent women have had incontinence for between four and six years without seeking help for it; 25% have had problems for more than 16 years (even though half of this group say the problems affect their quality of life) ■

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Practical care managing incontinence, it also reduces incontinence and pad use.3 Continence services in the UK, however, follow many different models of service delivery and, as a result, services can sometimes seem inconsistent. A clinic option enables continuity of care and an increased opportunity to promote continence.

Referral criteria Most continence services are available to men and women of all ages. A bed-wetting clinic is normally available for children via the health visitor or school nurse. All services aim to assess and treat each individual referred to them with skill and sensitivity.

Before your appointment Before your appointment, you will be asked to keep a diary (sometimes called a bladder diary, or frequency volume chart) of how often you go to the toilet to pass water. It is important to keep the diary for three days, as this gives a clear picture of how your bladder is behaving.

It is also important to keep a record of your fluid intake, noting the volume and type of drink (tea, coffee, water and so on). You will also be asked to bring a list of medications that you are taking, or have taken in the past, with you to your first appointment. You may be asked to complete a symptom profile before your appointment; this enables the nurse to identify the most bothersome of your symptoms and can help focus the treatment plan (see the instructions and list in Table 1).

First visit and follow-up During the initial assessment/appointment you will be asked specific questions about your: ● Medical history (relating to continence) ● Surgical history (relating to continence) ● Obstetric history (issues relating to pregnancy or childbirth, obviously for women only) ● Family history of enuresis (bed-wetting) ● Medication (if you are taking any) ● Fluid intake ● Degree of incontinence ● Problems with constipation.

Key points ● It has been suggested that nurse-led services result in reduced symptoms of incontinence, frequency, urgency and a need to go to the toilet at night. ● During the initial assessment/appointment at a clinic, you will be asked specific questions about your medical history and continence issues. ● After your appointment, the nurse will plan the most appropriate management strategy with you.

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Table 1. Recognise the symptoms Please read through all statements before ticking those most relevant to you. Feel free to add comments: • I leak when I laugh, cough, sneeze, run or jump • I only ever leak a little urine • At night I only use the toilet once or not at all • I always know when I have leaked • I leak without feeling the need to empty my bladder • Only my pants get wet when I leak (not my outer clothing) or I sometimes wear a panty liner • I feel a sudden strong urge to pass urine and have to go quickly • I feel a strong uncontrolled need to pass urine prior to leaking • I leak moderate or large amounts of urine before I reach the toilet • I feel that I pass urine frequently • I get up at night to pass urine at least twice • I think I had bladder problems as a child • I find it hard to start to pass urine • I have to push or strain to pass urine • My urine flow stops and starts several times • My urine stream is weaker and slower than it used to be • I feel that it takes me a long time to empty my bladder • I feel as if my bladder is not completely empty after I have been to the toilet • I leak a few drops of urine on to my underwear just after I have passed urine There will also be a mobility and manual dexterity assessment. You may be examined, but consent will be asked and you can have a chaperone present if you wish.

General examination may consist of: ● A routine urine test ● A bladder scan (if appropriate; for example, if residual urine levels are to be measured) ● A vaginal examination for women and a pelvic floor assessment (for men and women) by a clinic nurse ● A rectal examination (if appropriate).

Following your appointment, the nurse will plan the most appropriate management strategy with you; this will include: ● Advice on fluid intake and diet ● Pelvic floor exercises ● Bladder retraining ● Tablets to calm the bladder ● Advice on products to contain incontinence ● Referral to the GP and subsequently to a physiotherapist, urologist or gynaecologist as deemed necessary ■ References 1. Borrie MJ, Bawden M, Speechley M, Kloseck M. Interventions led by nurse continence advisers in the management of urinary incontinence: a randomized controlled trial. CMAJ 2002; 166: 1267–1273.

2. Moore KH, O’Sullivan RJ, Simons A et al. Randomised controlled trial of nurse continence advisor therapy compared with standard urogynaecology regimen for conservative incontinence treatment: efficacy, costs and two year follow up. BJOG 2003; 110: 649–657.

3. Williams KS, Assassa RP, Cooper NJ et al. Clinical and cost-effectiveness of a new nurse-led continence service: a randomised controlled trial. Br J Gen Pract 2006; 55: 696–703.

Additional information Please note, Deborah Rigby is now working as Programme Manager for Elective Care, Commissioning, NHS Bristol.

CHARTER CONTINENCE CARE ISSUE 18

Medical insight

Can stem cells end incontinence?

Stem cell therapy has been portrayed as a possible solution to most medical problems.

Helen Bolton looks at the possibility that it could soon be used to prevent incontinence

What are stem cells?

Stem cells are cells that are marked out by three unique properties. ● They do not have a specialised function – the majority of cells within the body are highly differentiated (specialised) and have one specific function (for example, blood cells are very different from liver cells). Stem cells are cells that have not yet specialised. ● They have the capacity to keep multiplying – unlike most cells in the body, stem cells can continue to multiply and renew themselves for prolonged periods through cell division. ● They are able to differentiate – when stem cells divide and multiply, they can either become another identical stem cell or, if exposed to certain conditions, differentiate (meaning that they can become a new cell with a more specialised function; for example, a nerve cell, a blood cell or any other type).

There are two major categories of stem cell, which have quite different characteristics: ● Embryonic stem cells ● Adult stem cells.

Embryonic stem cells Embryonic stem cells are cells that have been isolated and cultured (grown) from human embryos. The embryos used to create stem cells are obtained from patients who have had in vitro fertilisation (fertility treatment) and chosen to donate any remaining embryos that they no longer need.

Somatic stem cells (adult stem cells) Adult stem cells are found in small numbers among some of the specialised cells in tissues and organs throughout the body and are

CHARTER CONTINENCE CARE ISSUE 18

PHILIPPE PLAILLY/EURELIOS/SCIENCE PHOTO LIBRARY

A lot of media attention is given to reports promising stem cell cures for illnesses such as heart disease, diabetes and Parkinson’s disease.

Less attention is given to the potential application of stem cell therapy for more common, but debilitating, conditions such as urinary incontinence. Although recent research has been valuable, there are still major hurdles to overcome before stem cell therapy can become a safe and effective treatment.

A researcher using a light microscope to examine embryonic stem cells (one can be seen on the screen)

important for the maintenance and repair of these tissues. Adult stem cells are thought to remain inactive for long periods until they are triggered by injury or disease, when they respond by dividing and differentiating, providing new specialist cells to replace or repair damaged tissue.

Differences between stem cell types Stem cells differ in their ‘potency’ (their ability to differentiate into different specialist cell types). Embryonic stem cells are classified as ‘pluripotent’, meaning that they can potentially become any, or all, of the different types of specialist cells present in the body. Adult stem cells are classified as ‘multipotent’, meaning that they are more limited in their specialisation potential and can generally only give rise to a limited range of specialist cells (usually the cell types of the tissues in which they are present).

The use of human embryos as a source of stem cells has provoked a debate among the public, the scientific community, religious groups and politicians, and it is unlikely that there will be a consensus viewpoint in the near future. In contrast, adult stem cells have no significant ethical issues related to their use, as they are not made from human embryos.

Dr Helen Bolton BSc MRCOG Clinical Research Fellow in Translational Medicine, Wellcome Trust/Cancer Research UK, Gurdon Institute, University of Cambridge

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Medical insight Stem cell therapy By understanding the mechanisms that act to trigger stem cells to differentiate, scientists may be able to control the process and direct stem cells to grow into the specialised cell and tissue types that a particular patient requires. The hope is that these new healthy cells could be used to treat patients, usually by replacing damaged or deficient tissue.

Adult and embryonic stem cells have different properties and potentials, and their own unique benefits and problems, if used for therapy. Embryonic stem cells are readily available and can be grown easily in the laboratory in large quantities. As these stem cells have the potential to make all types of cell in the body, scientists need to devise very specific methods to direct them to become the type of tissue needed for a particular patient; this is very challenging and is currently a major area of research.

In contrast to embryonic stem cells, adult stem cells are already limited to the type of tissue that they can become.

By using adult stem cells, it may be easier to direct the cells to become the required tissue type, but the problem is that they are only present in very small numbers in the body and are difficult to identify and isolate. Therapies will need to use large numbers of cells and the techniques for growing and expanding adult stem cell numbers (cell culture) have not yet been fully worked out.

Recent research has focused on developing ways to change, or reprogramme, an adult cell into a cell that has the same properties as an embryonic one. There is the potential to develop stem cell therapy that combines the benefits of both types of stem cell, while minimising the ethical dilemma of using human embryos.

Immune rejection and other concerns If patients are treated with stem cells that have been grown from an embryo or unrelated donor, there is a chance that the new cells could be rejected by the patient’s immune system (much like the rejection of an organ transplant).

Patients may need to take immunosuppressive (antirejection) drugs, which often have side-effects. However, this problem may be avoided if patients are treated with their own stem cells. Adult stem cells could be taken from the patient, grown in culture to produce large numbers of the required cell type and then reintroduced into the patient; this would mean that the patient’s immune system would not reject the new cells.

By their nature, stem cells have the ability to self-renew and divide almost indefinitely (a characteristic common to cancer cells). There is, therefore, concern that stem cell treatment could cause cancer. There is also the worry that stem cells could change into the wrong type of specialist cell, resulting in treatment failure or new health problems.

Treating stress incontinence Stress urinary incontinence is the most common type of incontinence, affecting a large number of people, and it can impact on quality of life significantly. It is commonly caused by a weakness in the urethral sphincter, which is a muscular valve in the urethra (the tube connecting the

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bladder to the outside). This acts to keep the bladder closed, preventing leakage of urine. With increasing age, or as a result of injury, there is a reduction in the number of muscle cells around the urethral sphincter and this means that the bladder is more likely to leak urine.

It has been proposed that stem cells be used to create specialist cells that could replenish deficient muscle cells in patients with stress incontinence. It is hoped that these cells would enhance the function of the urethral sphincter and thus prevent incontinence. This approach could either use muscle cells grown from human embryonic stem cells, or cells harvested from adult stem cells already present in the patient’s own muscle (for example, from an arm or leg).

Research from the USA predicts that future treatment for stress incontinence could be as easy as two simple outpatient visits.1 At the first visit, patients would have a muscle biopsy (a sample of cells taken from their muscle through a needle). This sample would then be sent to a specialist stem cell laboratory, where scientists would use the sample to isolate, process and prepare stem cells ready for the patient’s treatment. The resulting stem cells would be injected into the patient’s urethral sphincter (a minor procedure using local anaesthetic to minimise discomfort).

Positive results from early studies Stem cell treatment has now been tested on small numbers of women with incontinence and the results have been promising.2 Much larger studies are now under way.

Current treatments for stress incontinence include physiotherapy, drug treatment and surgery. While surgery is usually successful, it can have complications and for some patients the improvement in symptoms may not be long lasting. The hope is that stem cell therapy for stress urinary incontinence will result in better cure rates, together with a lower chance of complications. However, it is vital that stem cell therapy is proven to be at least as effective and safe as current treatments before it is routinely offered to patients. There hurdles to overcome, but recent advances offer hope that stem cell therapy may eventually deliver great benefits to patients with a wide range of medical problems, including incontinence ■ References 1. Furuta A, Jankowski RJ, Honda M et al. State of the art of where we are at using stem cells for stress urinary incontinence. Neurolourol Urodyn 2007; 26: 966–971.

2. Carr LK, Steele D, Steele S et al. 1-year follow-up of autologous muscle-derived stem cell injection pilot study to treat stress urinary incontinence. Int Urogynaecol J Pelvic Floor Dysfunct 2008; 19: 881–883.

Key points ● Some types of stem cell have the potential to become any other type of cell in the body. ● It has been proposed that stem cells be used to create specialist cells that could replenish deficient muscle cells in patients with stress incontinence. ● There are still major hurdles to overcome before stem cell therapy is condsidered safe and effective.

CHARTER CONTINENCE CARE ISSUE 18

My best-kept secret

Tara Willson

Performing intermittent self-catheterisation (ISC) is often something that people keep hidden from friends and family and undertake in the privacy of their own homes. In this article, Tara Willson – who uses SpeediCath – reveals her story My disability is hidden and all my life I’ve struggled to keep it a secret. Many people have no idea that I have a disability, and for me it’s a daily personal challenge. I was born with spina bifida in 1966. The spinal cord was fused to the spinal bones. Surgery was performed when I was 18 months old, releasing the cord, but damaging the nerves to the bladder and bowel in the process, leaving me doubly incontinent.

I became aware of being different from a very young age and remember the difficulties at school, the shame and the feeling of ‘being different’. After having many urinary tract infections (UTIs), it was recommended that I have a urostomy. At the time this was irreversible and, having heard of the positives of ISC, my parents refused the urostomy and demanded a second opinion.

My mother persuaded the hospital to teach her and I remember the first time she tried to catheterise me. The catheter was solid metal and about eight inches long; I took one look at this strange object and started crying.

No one sat me down to tell me what the catheter was meant to do and why.

My mum came into my primary school at least once a day for two years, but was catheterising me at least four times a day. It was all very noticeable and I hated the questions and taunting, not only from other pupils, but also from teachers. Once secondary school was looming, I didn’t want my mum attending every day, so I taught myself to self-catheterise. At the time, there were some comments like, ‘How could a 10-year-old manage to perform ISC?’, but I did, and I flourished. Personally, I feel that the earlier you teach someone to catheterise the better, and it gave me great independence. It boosts my selfesteem, cutting out the feeling of, ‘Am I wet. Do I smell?’

When I left school, I was determined to get a job, just like everybody else, and have always been in employment since. Physically, emotionally and financially, I have always been aware of how different I am. I’m the only person I

know who goes on holiday with their luggage weighing less when they return than when they went!

Travelling with a catheter in its own make-up bag, with spare pads and spare clothes takes careful planning.

Equipping myself now is not difficult, but finding somewhere suitable to use (and possibly change) a catheter can be. Imagine yourself on a fast-moving train, or in a small toilet on a plane, trying to catheterise – trying to sit/squat when in motion needs skilled juggling!

When in Egypt, I learnt to catheterise standing up in a matter of minutes, due to the less than hygienic toilets!

Keeping the secret is difficult, as I do not want to broadcast my problem to a new friend or employer.

Getting a job, in my experience, can be difficult, but not impossible. I’ve learnt over time that it’s best to inform your employer, as you stand more of a chance of keeping your job. As I’ve got older, I’ve become more adept at keeping my best-kept secret – secret! I look after my health, eat well, drink plenty and respond quickly to the first signs of a UTI. I am learning to manage my hidden disability and, for the first time in my life, openly speaking about it. This is such a taboo subject and I sometimes perceive that the UK is living in the dark ages when it comes to incontinence – we can’t, or will not, talk about it!

A few years ago, I was introduced to the Coloplast SpeediCath Compact intermittent catheter and it has given me so much more independence. We’ve come so far from solid catheters to small, compact, flexible and readyto-use friends. SpeediCath has given me confidence and improved my quality of life; it is all about being in control, and using this catheter has helped me achieve this.

I continue to challenge my disability; I work full time and approach life with humour. I want to raise awareness for the next generation and to make it easier for people to get support. And finally, to release my best-kept secret! ■

❛ Personally, I feel

that the earlier you teach someone to catheterise the better

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Psychological issues

Depression and incontinence It is well known that incontinence can cause depression, but in this article Jennifer Leddy looks at the evidence suggesting that depression can also be a cause of incontinence Jennifer Leddy Continence Nurse Specialist, Leicestershire Partnership NHS Trust, Leicester

Years ago, it was assumed that women who were urinary incontinent were depressed because they isolate themselves, do not go out as much and are embarrassed by the problem. Research has now uncovered additional explanations for the difference in the rates of depression found in women with and without urinary incontinence.1 Various theories of depression involve a person’s perception of ‘helplessness’ and lack of ability to cope. Studies show that depression improves after treatment of both stress incontinence (leaking urine due to movements such as coughing, laughing or sneezing) and urge incontinence. Women with urge incontinence predictably lose large amounts of urine with each leakage episode, resulting in greater anxiety (related to the feeling of greater loss of bladder control).2 Hence, women with urge incontinence report greater degrees of depression and a larger impact on quality of life than women with stress incontinence. Women with the latter who limit what they drink and avoid activities that can provoke urine leakage still tend to be more depressed than the general population, but not as depressed as those with urge incontinence.

Serotonin and the bladder Many cases of depression are the result of low levels of serotonin, a neurotransmitter (chemical messenger), found in the brain. The group of medications called selective serotonin reuptake inhibitors (SSRIs) increase the availability of serotonin and decrease the symptoms of depression. Some SSRIs have the side-effect of causing urine retention, leading

Key points ● Women who suffer from continence issues are more likely to suffer from depression than other women. ● Symptoms of depression have been shown to improve after treatment of stress or urge incontinence. ● A reduction in serotonin function, which leads to depression, can contribute to bladder problems.

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researchers to think serotonin may affect bladder function.

The association between depression and urge incontinence is consistent with the idea that a reduction in serotonin function can make a person more likely to suffer depression, and contribute to bladder overactivity. Descending serotonin pathways from the brain stem inhibit bladder contractions; thus, depression associated with altered serotonin function may make a person more likely to suffer urge incontinence.3 Zorn et al carried out work suggesting a strong association between depression and urinary incontinence,4 thought to be due to altered serotonin function, and to help explain the success of SSRIs in treating urge incontinence.

The data supported the theory that a reduction in serotonin leads to bladder problems.

Although urge incontinence may lead to depression, another theory is that these two conditions share a common development in the brain. Lowered serotonin leads to depression and urinary frequency. Thus, depression may not be the result of persistent urinary incontinence, but those with altered levels of serotonin could suffer both depression and an overactive bladder.5 The latter may lead to urge incontinence, urinary frequency, urgency or bed-wetting. This means antidepressant drugs may also help to manage urge incontinence.

Research shows the negative impact urinary incontinence can have on women, including an increased risk of anxiety and depression.

Equally, severe depression can cause a person to lose all personal pride or care and this can lead to incontinence in the more severe cases. It is essential that women with either depression or incontinence be screened for both conditions ■ References 1. Melville J, Walker E, Katon W et al. Prevalence of co-morbid psychiatric illness and its impact on symptom perception, quality of life and functional status in women with urinary incontinence.

Am J Obstet Gynecol 2002; 187: 80–87.

2. Vigod SN, Stewart DE. Major depression in female urinary incontinence. Psychosomatics 2006; 47: 147–151.

3. Mc Grother CW, Donaldson MM, Hayward T et al. Urinary storage symptoms and comorbidities: a prospective population cohort study in middle-aged and older women. Age and Ageing 2006; 35: 16–24.

4. Zorn BH, Montgomery H, Pieper K, Gray M, Steers WD. Urinary incontinence and depression. J Urol 1999; 162: 82–84.

5. Urogynaecology Specialists of Kentuckiana. Depression and Urinary Incontinence. http://www.urogynspecialists.com/ depression.htm (last accessed 27/08/09)

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Straight talking

Male pelvic floor problems There are a number of reasons why men can suffer from pelvic floor problems.

However, a little bit of exercise can normally improve the situation considerably The main problems that can affect the male pelvic floor are: urinary incontinence, faecal incontinence and erectile dysfunction. Each of these problems can cause men considerable distress and embarrassment.

Urinary incontinence The most prevalent types of urinary incontinence in men are: urge urinary incontinence, stress urinary incontinence and post-micturition dribble.

benefit from a full assessment by a continence specialist who can perform tests and give advice.

Importantly, men are advised to tighten their pelvic floor muscles up strongly when they increase the pressure inside their abdomen.

Some of the activities that cause an increase of pressure in the abdomen, on the bladder and on the pelvic floor are: sneezing, coughing, shouting, laughing, lifting, bending, rising from sitting, and running; men should tighten their pelvic floor muscles before and during these exertions, so that it becomes a habit. Men may also be advised to lift the pelvic floor slightly

Grace Dorey PhD FCSP Emeritus Professor, University of the West of England, Bristol; Extended Scope Practitioner, North Devon District NHS Hospital, Barnstaple; Consultant Physiotherapist, Nuffield Health Taunton Hospital, Somerset

Urge urinary incontinence

Stress urinary incontinence Stress urinary incontinence is ‘the complaint of involuntary leakage on effort or exertion, or on sneezing or coughing’.1 Stress urinary incontinence is almost always as a result of surgery, although it can be related to neurological diseases and weak pelvic floor muscles. Men are particularly at risk after undergoing radical prostatectomy, radiotherapy or transurethral resection of the prostate.

Like men with urge urinary incontinence, those with stress urinary incontinence can

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There are several exercises that men can perform each day to strengthen their pelvic floor muscles

MARTIN RIEDEL/TAXI/GETTY IMAGES

Urge urinary incontinence is ‘the complaint of the involuntary leakage of urine accompanied by, or immediately preceded by, urgency’.1 Urge urinary incontinence is very distressing, and often occurs just before men reach the toilet.

Panic makes the problem worse.

Men with urge urinary incontinence can benefit from a full assessment by a specialist continence physiotherapist or a continence nurse specialist, who will be able to perform a gentle anal examination to test the strength and endurance of the pelvic floor muscles (see Box 1). If the pelvic floor muscles are weak, men are advised to perform pelvic floor exercises to increase the tone in these muscles.

Urge suppression techniques are particularly useful: when men have an urge to visit the toilet, they are advised to stand still or sit down and relax for one minute until the ‘urge’ disappears and the bladder settles down. When the urge has disappeared, they are advised to walk calmly to the toilet. The important message is not to rush to the toilet mid-urge.

Box 1. Pelvic floor function The male pelvic floor muscles form a muscular sheet across the outlet of the pelvis and can be voluntarily contracted. The male pelvic floor muscles have many functions, including: ■ Supporting the abdominal contents ■ Controlling urine ■ Controlling faeces ■ Stopping post-micturition dribble ■ Achieving and maintaining penile erection ■ Pumping the ejaculate Weak pelvic floor muscles may impair any of these functional activities

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Straight talking

Ureter Bladder Ischiocavernosus muscle

Rectum Prostate gland Pubic bone Pelvic floor muscles

Bulbocavernosus muscle

Transverse perineal muscle

Levator ani

Anal sphincter

Gluteus maximus muscle

Urethra

Figure 1. The deep pelvic floor muscles

Figure 2. The superficial pelvic floor muscles

when they are walking, as this increases the endurance of the muscles.

Figures 1 and 2 show the deep and superficial male pelvic floor muscles.

Post-micturition dribble Post-micturition dribble is the term used ‘when an individual describes the involuntary loss of urine immediately after he has finished passing urine, usually after leaving the toilet in men’.1 It is a common problem for men of all ages, but particularly troublesome in older men.

Urine may stay in the u-shaped portion of the urethra after men have passed urine; this can dribble with movement.

Men who suffer from post-micturition dribble are advised to tighten their pelvic floor muscles up strongly after passing urine.2 This tightening will empty any urine left in the u-shaped portion of the urethra, while men are still poised over the toilet.

Faecal incontinence There are several types of faecal incontinence. It may be related to constipation, poor mobility, poor vision, impaired consciousness, neurological conditions, anal sphincter injury, diarrhoea and evacuation dysfunction.

Treatment of faecal incontinence A detailed assessment should be made by a specialist continence physiotherapist or continence nurse specialist, so that appropriate treatment for faecal incontinence can be provided. The therapist will perform a gentle anal examination to assess the strength, endurance and integrity of the pelvic floor muscles. The correct exercise programme can then be ‘tailor-made’ for each individual.

If physiotherapy is not the desired treatment, patients will be referred on to the most appropriate professional.

Risk factors that contribute to constipation, such as poor diet, the side-effects of medication or sedentary lifestyle, need to be addressed. Mild laxatives may be prescribed to soften the stool. It is also important to make sure men have audio and visual privacy when using the toilet. Men who have faecal urge incontinence may be helped by

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Glans penis

Corpus cavernosum Corpus spongiosum

Pelvic floor muscles

Urethral bulb

Figure 3. The anatomy of the penis

strengthening the external anal sphincter and the pelvic floor muscles to prevent faecal leakage following an urge to pass a motion. It helps to tighten the pelvic floor muscles slightly while walking to the bathroom to stop faecal leakage. It may be prudent to cut down on foods such as onions, curries, chillis and caffeine products, which stimulate the smooth muscle of the gut and can make faecal urgency worse. Caffeine intake should be reduced slowly over a three-week period to avoid feeling unwell. For those men with poor mobility and poor dexterity, it may help to wear clothes that are easy to unfasten and to have ready access to a toilet or commode.

Men with prolonged diarrhoea should visit the GP, who will assess patients individually. The GP will review medication and may conduct further tests for infection and bowel disease.

Erectile dysfunction The penis (see Figure 3) is also affected by the pelvic floor muscles. Erectile dysfunction is defined as ‘the inability to achieve or maintain an erection sufficient for satisfactory sexual performance (for both partners)’.3 The degree of erectile dysfunction may be graded according

CHARTER CONTINENCE CARE ISSUE 18

Box 2. Pelvic floor muscle exercises for men 1. Lying down ■ Lie on your back with your knees bent and held apart. Tighten your pelvic floor muscles as if you were trying to prevent wind from escaping and trying to prevent urine from leaking. Your testicles should rise slightly and the base of your penis should move slightly into your body ■ Hold the contraction as strongly as you can ■ Try to avoid holding your breath or tensing your buttocks.

Your lower abdomen will tighten too ■ Perform three maximal contractions in the morning (holding each for up to ten seconds) ■ Perform three maximal contractions in the evening (holding for up to ten seconds) 2. While sitting ■ Sit on a chair with your knees apart and tighten your pelvic floor muscles as if you were trying to prevent wind from escaping and trying to prevent urine from leaking.

Your testicles should rise slightly and the base of your penis should move slightly into your body ■ Hold the contraction as strongly as you can ■ Try to avoid holding your breath or tensing your buttocks. Your lower abdomen will tense too ■ Perform three maximal contractions in the morning (holding for up to ten seconds) ■ Perform three maximal contractions in the evening (holding for up to ten seconds) 3. While standing ■ Stand with your feet apart and tighten your pelvic floor muscles as if you were trying to prevent wind from escaping and trying to prevent urine from leaking

to the number of satisfactory attempts out of ten (mild: seven to eight, moderate: four to six, and severe: zero to three).4 Erectile dysfunction can have a profound effect on men’s quality of life, resulting in loss of self-image and depression and can severely impact on the quality of life of their partners.

Treatment of erectile dysfunction There is a range of treatments to help men with erectile dysfunction, such as oral medication, penile injections, urethral pellets, vacuum devices and surgery. Men are advised to perform pelvic floor exercises either alone or in combination with other treatment (see Box 2).

Research has shown that 40% of men who experienced erectile dysfunction for six months or more, and performed daily pelvic floor exercises for three to six months, regained normal erectile function; a further 35% of men were improved.5 If the pelvic floor musculature is poor, muscle strengthening may help to improve erectile function and prevent erectile dysfunction. The adage ‘use it or lose it’ applies aptly to the pelvic floor muscles ■ References 1. Abrams P, Cardozo L, Fall M, Griffiths D et al. The Standardisation of Terminology of Lower Urinary Tract Function: Report from the Standardisation

CHARTER CONTINENCE CARE ISSUE 18

■ If you look in a mirror, you should be able to see the

■ ■ ■ ■ ■

base of your penis move nearer to your abdomen and your testicles lift Hold the contraction as strongly as you can Your lower abdomen should tense Try to avoid holding your breath or tensing your buttocks Perform three maximal contractions in the morning (holding for up to ten seconds) Perform three maximal contractions in the evening (holding for up to ten seconds)

4. ‘The knack’ ■ Tighten your pelvic floor muscles just before and during activities that increase your abdominal pressure such as coughing, sneezing, lifting and getting out of a chair 5. While walking ■ Lift your pelvic floor up slightly while walking 6. After urinating ■ After you have voided urine, tighten your pelvic floor muscles up strongly to eliminate urine from the u-shaped portion of the urethra 7. After passing a motion ■ After passing a motion, tighten your anal sphincter before wiping your bottom. This helps to return any faeces not voided back up the anal canal to the rectum 8. During sexual activity ■ Try tightening your pelvic floor muscles rhythmically to achieve and maintain a hard penis during sexual activity.

Slow thrusting movements generate higher pressures inside the penis

Sub-committee of the International Continence Society. Neurourology Urodyn 2002; 21: 167–178.

2. Dorey G. Why bulbar urethral massage is outmoded as a treatment for postmicturition dribble in men. Association for Continence Advice Journal 2003; 23: 30–32.

3. NIH Consensus Conference. Impotence. NIH Consensus Development Panel on Impotence. JAMA 1993; 270: 83–90.

4. Albaugh J, Lewis JH. Insights into the management of erectile dysfunction: Part I. Urol Nurs 1999; 19: 241–247.

5. Dorey G, Speakman M, Feneley R et al. Randomised controlled trial of pelvic floor muscle exercises and manometric biofeedback for erectile dysfunction. Br J Gen Pract 2004; 54: 819–825.

Key points ● The main problems that can affect the male pelvic floor are: urinary incontinence, faecal incontinence and erectile dysfunction. ● The male pelvic floor muscles perform many important functions for the body, including controlling urine and faeces. ● If the pelvic floor muscles are weak, men are advised to perform pelvic floor exercises to increase the tone in these muscles.

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Resources

Depression Alliance

Prostate UK

The Pelvic Partnership

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Depression Alliance is the leading charity in England dedicated to people with depression and has been in existence for over 25 years. We are a member-oriented charity and focus our efforts on sharing and promoting good practice, providing support, practical advice and activities that can make a difference to people who have, or have experienced, depression. We also promote and encourage research into the causes and prevention of depression. Our main activities are the co-ordination of: ● Self-help groups – these are a national network of user-led support groups ● A new resource website with the most up-todate information on treatment for depression ● A Single Step – our quarterly newsletter

● DA Talk – a self-help chat room open only to our members ● Pen friend – a scheme whereby people with similar interests write to each other ● The Employment and Well-being project, in Croydon, which runs a ‘time bank’ where people with depression support others by trading skills and offering practical support ● Various publications ● Depression Awareness Week, which takes place each April.

If you are interested in joining Depression Alliance please give us a call.

Tel: 0845 123 2320. email: info@depressionalliance.org website: www.depressionalliance.org

Prostate UK is the only national charity dealing with all forms of prostate disease, including benign and malignant prostate cancer. One in two men will suffer from a prostate disease at some stage in their lives. We seek to limit the damage this causes by raising awareness, providing information, funding research and training medical professionals. We do this without any government funding. Our mission is to stop prostate diseases ruining lives. We aim to achieve this by: ● Funding research into greater understanding and development of new techniques – since 2000 we have sponsored some 120 projects costing around £3.4 million ● Producing brochures on each prostate disease – including advice on healthy living, prevention, erectile dysfunction and

continence. Our newsletter Update is also full of valuable information ● Informing and training medical professionals, both specialist and non-specialist, in the latest advances in the treatment of prostate diseases.

We also run free training seminars across the UK, which hundreds of GPs and nurses attend ● Organising campaigns to raise awareness and ensure men have access to the most up-to-date information, receive prompt and appropriate treatment and support, and are able to make the best decisions for their individual circumstances ● Offering advice, help and, above all, hope to those affected by prostate problems.

Tel: 020 8788 7720. email: info@prostateuk.org website: www.prostateuk.org

The Pelvic Partnership is a support group run by, and for, women with pregnancy-related pelvic girdle pain (PGP) or symphysis pubis dysfunction (SPD). We provide information and support to families and healthcare professionals. PGP and SPD are pain in the pelvic joints during movements such as walking, climbing stairs or turning in bed. The pain is usually caused by slight misalignment of the pelvic joints. The condition affects up to one in four pregnant women, with varying severity. It is treatable by gentle mobilisation techniques.

Early diagnosis and appropriate manual treatment will help to minimise long-term discomfort. If left untreated, the condition often

continues for a long time after birth and interferes with normal day-to-day life. Many women with PGP and SPD also experience problems with continence, as the pelvic floor muscles can stop functioning (normally due to pain). Often, having this pain treated improves, and in some cases completely resolves, any continence problems. If you experience pain, you should ask your midwife, GP or hospital doctor for a referral to a physiotherapist, osteopath or chiropractor experienced in treating pelvic joint problems and SPD. You can contact the Pelvic Partnership for support and information.

Tel: 01235 820 921. website: www.pelvicpartnership.org.uk

CHARTER CONTINENCE CARE ISSUE 18

Forum

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

My husband suffered a severe stroke several years ago and, as a result, has used a Conveen sheath ever since. I am strongly opposed to catheters being used unless really necessary. Due to advancing years, the penis, at times, retracts and the Conveen comes off.

Is there anything to fix this problem?

Mrs J, Cornwall Ann Winder RN Senior Continence Specialist, Park Drive Health Centre, Baldock

As a sufferer of hereditary spastic paraplegia, I had been wearing sheaths and leg bags for about 15 years. Now, approaching 70, after a phase of urinary infections (and a blockage or two) I have been fitted with an indwelling catheter for five months.

I would like to suggest something that my wife invented for me a few weeks ago that might be of interest to you. In order to minimise the spread of the daily penile discharge, which I think most people try to cope with by application of toilet paper or other tissue, we thought we would try something that we jokingly call a ‘willy-warmer’.

This is a baby’s white sock, on the closed end of which we cut a small hole, through which the catheter and flip/flow valve can be pushed, and then the sock can be pulled up along the penis. These items wash easily and I change into a new one each morning after bathing/washing. The gain is that I can maintain clean underpants, and do not have to use tissue paper.

Perhaps a more efficient, developed alternative along these lines could be a beneficial invention!

Mr M (via email) Thank you for the tip; your wife’s idea is certainly novel. You say that you have had the catheter for five months. I assume that you have had this changed as recommended by the maker of your catheter – usually every six to 12 weeks (but they are all different). If the same catheter is used for five months then this leads to discharge around the penis and it will become difficult to change ■

CHARTER CONTINENCE CARE ISSUE 18

I have been on intermittent selfcatheterisation for the last eight years and, on average, I contract an infection once every 18 months despite meticulous adherence to the ‘no-touch’ technique. This year I flew to Australia, travelling out club class and returning in first class. I was free of infection on the flight out, but ten hours after my return to Heathrow I was not so fortunate. I attributed this directly to the problems I faced due to the design of the toilet.

Normally I do not have a problem with washing the genitalia in sinks.

However, in the plane I travelled back in there was a very small washbowl and a single tap with three buttons on its upper surface. The buttons were labelled drain, hot, and cold and it was necessary to press these quite hard. It is inevitable that the surface of these taps will be contaminated with Escherichia coli (E. coli ).

I could not find a solution to this problem and had to depress the buttons with the tips of my little and fourth fingers as they were stiff. I had hoped that I would avoid contamination of the SpeediCath as it was removed from its covering, but I did not succeed on the return journey. Any comments or suggestions you have would be welcome.

Mr T, Surrey Keeping clean is extremely difficult on any flight, with or without additional problems.

You could use a medical wipe for the tap and a baby wipe for cleaning around the penis, instead of water. Both wipes can be bought from a chemist. Unfortunately, it does mean carrying extra equipment with you on your travels and an extra cost. I would be interested to see any comments that the airline may send to you, as many people contact us regarding similar issues ■

This is a very common problem and there are ways to secure the sheaths. I would advise that you get in touch with your local continence service. An adviser will be able to come and visit you and suggest alternative treatments for your husband ■

Charter

I have started passing water at night when in bed and don’t know anything of this until I wake up soaked. Could you please help me by supplying whatever is necessary to help with this problem (pads, pants and so on – you will know best); also, could you please give any professional advice on this subject that you have.

Mr J, Hertfordshire I’m afraid I cannot give you advice, as I do not know why you are having problems at night. I highly recommend you speak with your doctor or local specialist nurse ■

Address your correspondence to: The Editor,

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.

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