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C h a p t e r 5 : C o n t r o l l i n g u r i n a r y i n c o n t i n e n c e
Achieving control of urinary continence is the key Incontinence impacts on all aspects of daily
to achieving an independent lifestyle. A wide range of interventions and resources exist to assist in the Incontinence can prevent people with spina bifida from successful management of urinary incontinence. achieving full participation in all aspects of life, such as This chapter provides the clinician with an introduction work, education, personal relationships and general to management principles, some resources and also outlines the roles of specialist clinics in the management activities of daily living. In addition, incontinence is of incontinence (for issues of faecal incontinence, see almost a taboo subject, viewed by many in society as a Key issues for clinicians
Impact on self esteem
• Incontinence impacts on all aspects of life. Successful Incontinence also brings many other daily problems, management of incontinence overcomes a major such as changing beds, and clothes, washing soiled barrier to personal and social independence.
linen and clothing, constant worry over possible • Incontinence is best managed in conjunction with a episodes of incontinence, embarrassment, shame at soiling in public, accusing looks from teachers, workcolleagues and the general public — all leading to • Most young people and adults with spina bifida will difficulty in coping with daily life.
have already established incontinence management.
These issues can lead to poor self esteem, contributing The role of the general practitioner is largely one of to a sense of frustration, guilt, fear and isolation, making review and detection of management problems. These can then be referred to a specialist clinic if indicated.
• Conservative management is the first step to Continence control — the incontinence
management team
• Clean intermittent catheterisation is a common and There are many resources and health care providers important component of incontinence management.
available for achieving successful continence control and Clinicians need to familiarise themselves with this GPs can help link people with spina bifida to these specialist clinics. Not only are there specialist teams to • Incontinence management procedures need to be help children, but clinics for young people and adults with reviewed after a urinary tract infection.
spina bifida also exist (see Chapter 9 Organisations and • Persistent changes in continence patterns should be Clinicians having problems identifying nearby adult treatment centres may be able to obtain their location by • There are surgical interventions available to assist contacting a paediatric treatment centre.
incontinence management if conservative measuresfail. These are organised through specialist clinics.
Overview of bladder and urinary tract
• Clinicians need to be aware of the existence of management1–2
possible latex allergies when treating patients with Common approaches to the management of bladder and other urinary tract problems in spina bifida involve acombination of the following: 88 • Australian Family Physician Vol 31, No. 1 January 2002; Special feature Chapter 5: Controlling urinary incontinence
• conservative management including pharmacological Intermittent catheterisation
Intermittent catheterisation of the bladder allows it toempty, in order to prevent retention, reflux and other All continence control needs to be managed under the complications, and to help control incontinence. direction of a urologist and continence clinic. Many adultswith spina bifida are unaware of these resources, and GPs can greatly improve quality of life by referring patients In the presence of nerve damage, the person with to these specialist centres. The GP remains a key player spina bifida may have difficulty telling the difference in this team as the first point of contact for patients.
between a full bladder and a full bowel.
Sensation from the muscle wall of overstretched bladders are weak or nonexistent.
The following procedures are described to familiarise Detruser sphincter dyssynergia can either cause a clinicians with common approaches to bladder rush of urine flow when the sphincter does open, management. Treatment should only be initiated under and usually occurs at inconvenient times, or may just the direction of a urologist, or a spina bifida or continence cause a dribble when the urinary bladder pressurerises above a certain level.
Swimming and drinking will increase the urine output.
Conservative management
Anxiety, shocks and excitement can precipitateepisodes of incontinence.
Conservative management of bladder problems usually Sensations such as abdominal ‘pain’ can be confused involves a combination of clean intermittent catheterisation with bladder or bowel fullness sensations.
(CIC) and the use of pharmacological agents.
Incontinence control routines can be upset by intermittentinfections, procedures, illnesses and other precipitating Establishing a routine
The key to successful incontinence control is to establishincontinence management procedures as part of every day This simple, clean (not sterile) procedure repeated a living. When incontinence control becomes a problem, few times a day allows control of the timing of bladder the aim is then to re-establish these routines.
Clinicians need to be aware of differences in Clean intermittent catheterisation aims to achieve incontinence control for those affected by spina bifida.
continence by emptying the bladder at scheduled For example, the experience of many GPs will be in intervals, as well as reducing residual urine volume in children with normal bladders. Incontinence control order to prevent infection and bladder overstretching.
issues in spina bifida are wider than this; incontinence Intermittent catheterisation gives the person with occurs within the context of a neurogenic bladder, and spina bifida a great deal of control over incontinence, and is an ongoing issue for all ages for people with spina while achieving good technique may take some practice, the effort is well worthwhile and achievable. Selfcatheterisation requires good hand to eye coordination.
Timing is the key
Self catheterisation gives a young person or adult The key to successful control of urinary incontinence in increased self esteem through increased independence.
spina bifida is bladder timing. Only a small number of Self catheterisation also means that the person can attend people with spina bifida will be successfully bladder trained, but successful timing can be achieved in a Young people may have issues with compliance with self catheterisation and the clinician may need to check Successful bladder timing — that is, the regular that techniques are being followed. This may involve emptying of the bladder — allows the person to have referral to a specialist incontinence management team.
control and confidently participate in school, work and Reviewing catheterisation techniques
Establishing routines and regular practice is the first Many young people and adults with spina bifida will have step to achieving effective incontinence control. When already been using intermittent catheterisation for many routines become upset, this pattern can be used as a target years. In this case, the role of GPs seeing adult patients for the first time may not be to teach intermittent Australian Family Physician Vol 31, No. 1 January 2002; Special feature • 89 ■ Chapter 5: Controlling urinary incontinence
catheterisation, but to review technique, check that the Latex allergies
appropriate catheter type is being used and refer to Be aware that allergies to latex are more common in people with spina bifida than for the general population.
Catheterisation techniques should be especially Reactions can vary between mild reactions to severe reviewed when there is a change in continence pattern or anaphylactic shock. Clinicians need to remain alert to this after a urinary tract infection. Reusable catheters should possibility and to refer to specialist clinics for advice if the be replaced with single use catheters in the presence of a Case study: Betty is a 26 year old woman with Intermittent catheterisation
Catheterisation aims to empty the bladder to protect renal She has overflow incontinence, and although using a CIC routine — which she has been using for many function and to achieve social independence through years — needs continence pads. Wheelchair bound, prevention of incontinence. Catheterisation is a simple, she has oscillated between living at home and clean method of inserting a plastic catheter several times independently, the major issue being a constant smell a day to drain urine (Tables 5, 6). of urine, although she is desensitised to the smell.
She lacks confidence and seems to have given up any Catheterisation and the toilet
ambition of work. Apparently very disorganised, whenyou talk to her about the urine smell issue she becomes Catheterisation is usually performed in the toilet, as using distraught and angry. You encourage her to attend an this socially acceptable place helps to normalise the process adult spina bifida clinic and a continence nurse.
of urination. That is, the toilet is the same place used for The nurse reports that she is using inappropriate urination as that for continent people. Toilets are always pads, wrong sized catheter, and is not catheterisingfrequently enough. With some planning assistance available, even if they need to be cleaned afterwards. When and assigning a friend who will tell her if she smells, the catheter is correctly inserted, the person can hear the her continence control is much improved. Establishing urine fall into the water and knows that the catheter has control involves keeping the catheterisation routine been inserted sufficiently and into the correct orifice (for constant. Each time it is performed, it should be iden- women). In addition, sitting upright gives better drainage tical. Not only does this maximise effectiveness of theprocedure, but decreases risk of urinary tract infection.
and maximises the chances of using the correct method towithdraw the catheter — that is, downwards.
Catheterisation should be performed before emptying Pharmacological agents
The self catheterisation routine — the role of
Under the direction of a specialist, pharmacological specialist clinics
agents can be an important adjunct to intermittent Self catheterisation is a complex technique and is best catheterisation. Common agents include anticholinergics taught by specialist continence clinics. These clinics can such as propantheline bromide; musculotropics including adapt teaching to suit each individual according to their oxybutinin, and antimuscarinics such as tolterodine.
special needs and gender. However, clinicians can keep Adverse effects
copies of any instructions issued to the patient to assist inreinforcing key messages directed by the specialist clinics.
These agents can cause adverse central nervous system While establishing catheterisation techniques is often effects that can interfere with cognition, which may in done with the assistance of a specialist continence team, turn complicate any deficits already present the GP can assist by going through the patient’s technique (see Chapter 2 The impact of hydrocephalus and other to ensure that each step is performed correctly. A CNS conditions on case management.) checklist has been prepared to help clinicians ensure the These agents may also contribute to constipation, basic technique is adequate (Table 7), but more detailed which can contribute to faecal incontinence.
information and assistance is available from the specialist Surgical intervention
General practitioners with any questions can contact Surgical intervention for the management of incontinence the continence nurses or other health professionals of is an important option for people with spina bifida where continence clinics for further assistance.
other procedures, such as CIC are not feasible. 90 • Australian Family Physician Vol 31, No. 1 January 2002; Special feature Chapter 5: Controlling urinary incontinence
Table 5: Clean intermittent catheterisation Table 6: Clean intermittent catheterisation Catheter, cleansing solution, lubricating gel, Catheter, clean pad and clothing, lubricating gel, 3. Retract foreskin if not circumcised and wash the tip of the penis using a cleansing solution.
4. Clean the vulva with 3 swabs from front to back. 4. Hold penis upright and gently insert the catheter into the urethra. If resistance is met part way, 6. With one hand, hold the labia apart and see or feel rotate the catheter or use gentle but firm pressure on the catheter until the muscle relaxes. It mayalso help to take some deep, slow breaths.
7. With the other hand, place the tip of the catheter behind the clitoris. Insert gently until it enters the 5. When the urine flow has stopped, advance the urethra. Gently push in until the urine flow begins.
catheter one more inch to ensure the bladder isfully empty.
8. When the urine has stopped flowing, slowly pull out 6. Slowly remove the catheter liberally.
7. Males with foreskins should always push the foreskin back again after the procedure.
10.Wash hands with soap and water after washing 9. Wash hands with soap and water after washing and packing away equipment and cleaning toilet seat.
nonfunctional sphincter. This can lead to complications ofthe upper renal tract and can be a major source of Ensure that patients using reusable clean morbidity and mortality. This often results in high bladder pressure due to urinary retention. High bladder pressure catheterisation move to single use dispos- can result in long term urinary sphincter damage.
able catheters during a urinary tract infec-tion. After the infection has resolved, Surgical management of high bladder pressure
may involve a variety of techniques
There is a wide range of surgical options to manage In addition, there are many urological reasons for surgical incontinence in spina bifida that can be tailored to each interventions, all of which impact upon the control of individual. These procedures are constantly improving and increasing in technical sophistication, emphasising the The decision to proceed with surgical intervention for importance of patients receiving regular urological the control of urinary incontinence in spina bifida is a highly complex area. Indications for surgical intervention Overview of common surgical
of the urinary tract in spina bifida include: procedures
• persistent high urinary storage pressure• upper urinary tract deterioration The following is a list of common urological procedures used in spina bifida, and their more common indications.
• incontinence due to intrinsic sphincter deficiency (ISD).
Vesicostomy
High bladder pressure
Vesicostomy is indicated in the presence of persistent As discussed previously, the most common neurogenic hydronephrosis and recurrent urinary tract infection when pattern in spina bifida is an areflexic bladder with a the bladder continually fails to empty. This simple Australian Family Physician Vol 31, No. 1 January 2002; Special feature • 91 ■ Chapter 5: Controlling urinary incontinence
procedure which involves making a stoma from the Table 7: Checklist for reviewing selfcatheterisation technique bladder to the skin surface to allow drainage, has a lowrevision rate and allows normal growth and maturation.
• Have copies of any patient instructions for Vesicostomies are often performed as temporary procedures included in their medical history file to help check some of the following key issues.
• Patients may benefit from visual instruction using Urinary diversion
illustrations rather than verbal instruction if learning Urinary diversion can be used when augmentation procedures fail to work for many physical, personal and • The routine must be kept the same each time.
social reasons. Procedures include illeal and colon • Ensure that hands are washed at each point conduits and cutaneous ureterostomy.
• Ensure that the catheter is lubricated liberally.
Augmentation cystoplasty
• Instruct patients to be careful to prevent Augmentation cystoplasty involves surgically configuring contamination from clothes. This may be done byfolding the clothes upwards and using a peg to a segment of bowel to augment the bladder and correct keep clothes fastened and away from genital area.
vesicoureteric reflux. When deciding upon an • The bladder must be fully drained as incomplete augmentation cystoplasty, issues to consider include emptying is a common cause of urinary tract which part of the bowel to use, eg. illeum, stomach, sigmoid colon or other section. Complications can result – the full length of the catheter must be held from the mucosa of the segment of origin, such as below the level of the bladder throughout the haematuria when using gastric lining or mucus production when using sigmoid colon. Ureteric augmentation uses – gentle pressure is applied to the lower abdomen distended hydronephrotic ureters, if present, to augment after the flow of urine has been stopped.
the bladder. Other complications of augmentation can • The flow of urine is sometimes stopped if the sphincter closes on the catheter giving the include perforation, infection, mucus production, calculi impression of complete bladder emptying. This may and the potential for malignancy, although this risk is be indicated by resistance when removing the catheter and by lower urine output than expectedduring drainage. In this case, repeat the procedure Catheterisable stomas
Catheterisable stomas may be useful in patients unable to • Assess bowel habits: constipation may cause perform intermittent catheterisation due to lack of • Associate bladder emptying to the daily routine, dexterity or being wheelchair-bound. They also have a such as when getting up in the morning, after meal place when a urethra is unavailable, perhaps due to the presence of a stricture or a fistula.
• Also review techniques and any instructions given The Mitrofanoff procedure is the formation of an abdominal stoma which is then connected to the bladderwith a tubal structure such as the appendix. Urine is thendrained by passing intermittent urinary catheters. Forexample, in the Mitrofanoff appendix procedure, thestoma is created from the appendix and part of thecaecum with intact blood supply. The tip of the appendixis then buried through the bladder wall to create apassageway for urine. Other structures have also beenused, including: gastric tissue; fallopian tubes; ureters; andother parts of the bowel.6 Transurethral injection
Transurethral injection therapy is used to treat intrinsicsphincter deficiency and involves the submucosalinjection of a biocompatible substance such as collagen or 92 • Australian Family Physician Vol 31, No. 1 January 2002; Special feature Chapter 5: Controlling urinary incontinence
silicon. The efficacy of treatment depends largely upon selecting patients with suitable urodynamic patterns.3 The He is a highly motivated man who had a urinary advantage of submucosal injection is the low morbidity, diversion procedure when he was a toddler. He has but its main disadvantage is the lack of long term data on managed with a bag for years, but is beginning to realise that he has missed out on many activities suchas swimming and travelling and confides that he ‘can’t imagine a sexual relationship with the bag present’. He has also heard at a spina bifida meeting that his Pubovaginal slings are the treatment of choice for females kidneys may be affected. He is amazed when you advise with intrinsic sphincter deficiency although there is also a him that this procedure may be reversable, with him role for the procedure in some males Suburethral slings starting a clean intermittent catheterisation routine.
use a variety of techniques and materials and many series Enthusiastic to find out more, he is eager to visit theadult spina bifida clinic.
have included long term follow up. Native tissue, such asthe use of an autologous tendon, appears to be associatedwith less morbidity than using synthetic materials.
Patients must be monitored postoperatively to ensure were a more common first line treatment and may now bladder emptying takes place and that there is no upper wish to take advantage of more recently introduced augmentation procedures. Reversal of diversion allows theintroduction of a clean intermittent catheterisation regimen Artificial urinary sphincters
that may be more beneficial for renal function and Artificial urinary sphincters are implanted silicon devices promotes independence. This process can offer significant that close the urethra. The artificial sphincter may be benefits to a select group of patients, but motivation needs placed at the bladder neck or bulbar urethra. The artificial to be high as it involves considerable preoperative sphincter is regarded as the main treatment option for male preparation and a high degree of postoperative compliance patients with intrinsic sphincter deficiency. Again, post- to ensure effective clean intermittent catheterisation operative monitoring is essential to ensure that urinary References
tract complications due to the elevated bladder pressure 1. Donnellan S. Urological management of the patient with associated with an artificial sphincter are prevented.
spina bifida. Monash Medical Centre: Melbourne. 2001 2. Silveri M, Capitanucci MI, Mosiella G et al. Endoscopic Circumcision
treatment for urinary incontinence in children with a congenital neuropathic bladder. Br J Urol 1998; 82:694–7 Circumcision may be indicated in males, especially when 3. Royal Childrens Hospital. Clean intermittent catheterisation.
in the presence of recurrent urinary tract infections where Instruction sheet for males. Royal Childrens Hospital: circumcision can sometimes reduce their frequency.
4. Royal Childrens Hospital. Clean intermittent catheterisation.
Instruction sheet for females. Royal Childrens Hospital: Reversal of surgical procedures
Young people and adults with spina bifida may present 5. Sugarman JD, Malone PS, Terry TR et al. Transversely tubularised ileal segments for the Mitrofanoff or Malone having had a particular surgical technique for antegrade colonic enema procedures: the Monti principle.
incontinence at some stage in the past but without a recent urological review. Many options are not permanent, andcan be changed to suit the needs of the person at that timein their life.
In light of surgical advances there may now be further options for these patients to explore. Some of these patientsmay want to try alternate continence procedures and maywant to have their surgery reversed. Referral to a specialistcentre enables patients to explore the advantages anddisadvantages of each of these procedures.
Reversal of urinary diversion (also called undiversion) may be an option in motivated patients when physicalconsiderations allow. Patients may have had urinarydiversion procedures in the past when these procedures Australian Family Physician Vol 31, No. 1 January 2002; Special feature • 93

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Argumentation and evidence

ABSTRACT. This essay explores the role of informal logic and its application in thecontext of current debates regarding evidence-based medicine. This aim is achievedthrough a discussion of the goals and objectives of evidence-based medicine and a reviewof the criticisms raised against evidence-based medicine. The contributions to informallogic by Stephen Toulmin and Douglas Walton are explicated a

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