Continence Care Pathway - NHS South Gloucestershire

NHS SOUTH GLOUCESTERSHIRE 

Continence Care Pathways 

2009 

Training/Con Care Pathway/2009

BRISTOL AND WESTON 

CONTINENCE PARTNERSHIP 

NHS South Gloucestershire, North Somerset PCT, 

Bristol Community Health 

Continence Care Pathway 

Community 

2009 

2 

Misc/Con Care Pathway/2009

Contents 

Page 

3 Contents Page 

4-5 Introduction 

6-12 Guidelines to complete continence assessment forms 

13 Useful contacts 

14 CAS Philosophy 

15-16 Assessing Continence Step 1, 2 and 3 

17-18 Continence Care Pathway 1 Female Stress Incontinence 

19-20 Continence Care Pathway 1a Male Stress Incontinence 

21-22 Continence Care Pathway 2 Urinary Urgency 

23-24 Continence Care Pathway 3 Voiding difficulties 

25-26 Continence Care Pathway 4 Reflex 

27-28 Continence Care Pathway 5 Function - Cognitive 

29-30 Continence Care Pathway 5a Function – Mobility 

31-32 Continence Care Pathway 6 Nocturia 

33-34 Continence Care Pathway 6a Nocturnal Enuresis 

35-36 Continence Care Pathway 7 Constipation 

Appendices 

Page 

37-38 1. Continence assessment 

39 1a. Symptom Profile 

40 1b Frequency/volume chart 

41 1c Oxford Scale 

42 2 Drugs affecting bladder function 

43 3 Caffeine 

44 3a Fluid intake 

45 4 Fibre scoring 

46 4a Bristol Stool Chart 

47 4b Looking after your bowels 

48 4c Bowel diary 

49 4d Sitting position 

50 5 Barrier preparations 

51-52 6 Pelvic floor exercises – female 

53 6a Pelvic floor exercises – male 

54 Blank Page – for notes. 

55-56 7 Bladder re-training 

57-58 8 Prostate Symptom Score 

59-60 9 Policy for Entitlement to receive Incontinence Pads 

61 10 Continence in a Confused Older Person 

62 10a Continence Training Programmes 

3 


Introduction 

Continence Assessment in the Community 

The “Good Practice Guidelines in Continence Care” (Department of Health, 2000) states that 

all patients should be asked, as part of a holistic assessment if they have a bladder or bowel 

problem. For the purpose of this document the standard trigger question is “Do you have any 

problems with, or concerns about your bladder or bowel”? If the answer is “yes” a full 

continence assessment should be carried out. 

The care pathway aims to support professionals in undertaking a continence assessment, and 

to support clinical decision making rather than replace it. It encourages:- 

Clear guidance about current best practice 

Standardisation of care 

Audit of quality and effectiveness can be measured 

Outcomes which can be reviewed at regular intervals 

The aim of this continence care pathway is that every patient will achieve the fullest 

potential. There may be reasons why this may not happen and the ideal outcomes for a client 

may be reflected in the social or dependent continence categories. 

Acknowledgements 

This care programme is adapted from “The Updated Continence Care Programme for Adults” 

which was produced by Barts, The London NHS Trust, & Tower Hamlets Primary Care 

Trust, May 2002, and work completed by Continence Service in North Somerset PCT. 

Continence 

Continence is a “skill gained when a person learns to recognize the need to pass urine and/or 

bowel motion, has the ability to reach an acceptable place to void, is able to hold on until they 

reach an acceptable place to void, and is able to void/eliminate effectively on reaching that 

place” (Anderson 1988, cited Norton 1992). This is the ideal state for everyone. 

Incontinence 

Incontinence is “an involuntary loss of urine and/or bowel motion at an inappropriate time or 

in an inappropriate place. The amount can very from slight to copious. Incontinence is not a 

disease but is a symptom of an underlying disorder. (Anderson et al 1998, cited Norton 

1992). 

Social Continence 

The client is socially continent. This may involve using pads, appropriate appliance or 

internal device. (Fonda 1997). 

Dependent Continence 

This means the client being dependent on others to take them, or remind them to go, to the 

toilet. (Fonda 1997). 

4 


Care Pathways 

All clients going through a continence assessment and treatment process will visit each stage 

at a different rate. Practitioners should encourage their clients to follow the programme, as 

they will achieve at different rates. False hopes should not be given, and realistic goals 

should be set. These goals should be reviewed regularly, and progress noted. 

Success Criteria 

It is acknowledged that client attitude plays a very important part of a continence assessment 

and the outcomes of treatment programmes. Therefore when assessing a client with a 

continence problem it is important that the assessor is empathetic to the problem, and it able 

to encourage and motivate clients completing their treatment. 

Outcomes 

In this care programme, outcomes are related to client’s own goals. The effectiveness can be 

measured by the outcome of the care pathway and referral on. 

Record Keeping 

Health professionals will be using different types of record keeping. This documentation has 

been designed to slot into community practitioner’s documentation. A copy of the assessment 

form and care pathways used should be given to the client, allowing them ownership of the 

document. 

References:- 

Department of Health (Oct 2006) NICE Clinical Guideline 40 

Urinary Incontinence. The management of urinary incontinence in women. 

Department of Health (June 2007) NICE Clinical Guideline 49 

Faecal Incontinence. The management of faecal incontinence in adults. 

5 


Guidelines for completing the Continence Assessment /Care Pathway Forms 

The Continence Assessment Form has been designed as a patient held document, which can 

accompany the patient in whatever setting. However in the initial stages and at other 

subsequent time lapses it may be needed for audit purposes. A copy should be sent to the 

continence department, or to accompany a request for pads. 

Patient Details should be completed accurately. Pads cannot be supplied without a postcode. 

Referrer Details includes the referrer’s name, contact details and relation to the client. 

Assessor Details includes the name, title and contact no. of the person completing the 

assessment. 

Type of Problem 

Document the words used by the client. Is it getting worse? From who’s perspective? 

Previous treatment/investigations 

Ask the client if they are already seeing someone else who is dealing (or has dealt) with the 

problem, or who has asked them to request a further appointment should the problem reoccur. 

Current management. 

How does the client currently cope? Specify type and amount of pads. How often are they 

changed, and how wet do they get? Specify the size and style of sheath, receptacle etc. Is the 

client happy with current management? If so, what are they hoping to gain from your 

assessment? 

Relevant Medical/Surgical/Obstetric History 

Medical. Many medical conditions can affect the function of the bladder e.g. neurological 

conditions: - multiple sclerosis, diabetes, spinal injuries, stroke, dementia, back pain, chronic 

cough, depression, sexually transmitted diseases, (particularly Chlamydia causes urgency) 

physical and learning disabilities. Also note any history of sexual abuse. 

NB. Hormone Replacement therapy should be used with caution following breast cancer; 

however local oestrogen cream/pessaries can be used, anti cholinergic therapy is 

contraindicated with glaucoma, and certain cardiac arrhythmias 

Allergies should be documented. 

Surgical. Previous surgery should be documented, also any times when a catheter may have 

been in situ, including reasons. Pay particular attention to the following. 

Urological surgery e.g. TURP, TURBT, bladder neck surgery, radical prostatectomy, 

cystoscopy, urethral dilation and stricture therapy. 

Gynaecological surgery e.g. culposuspension, pelvic floor repair, hysterectomy, sling 

procedure, injectable urethral bulking agents. 

6 


Bowel Surgery e.g. bowel resection +/- stoma, including reversal, haemorrhiodectomy, 

fissure repair, sphincter repair. 

Obstetric 

Risk factors for stress incontinence include weight of baby (over 8lb/4kg), trauma 

(episiotomy, tear), assisted delivery (forceps, suction) length of labour (long or short 2 nd 

stage) epidural, number of babies, gaps between them, (less than 2 years). 

Medication 

Many drugs disturb bladder function. See Appendix 2. Prompt the client to mention over the 

counter remedies, particularly laxatives, and herbal remedies. Some recreational drugs may 

affect continence. 

Mobility, Dexterity and Personal Care. 

Identify the toilet position at home, distance, ease of access with aids, use of commode. 

Mobility should be noticed. It may be directly impaired e.g. due to pain, or indirectly, e.g. 

due to fear of falling. The speed of mobility may be an issue when the patient has urgency. 

Linked closely to mobility is manual dexterity, which may hinder removing clothes to use the 

toilet or in the fitting of aids or appliances. 

A patient’s posture on the toilet is important for successful elimination and they may require 

toilet frames, grab rails, or steps to rest their feet on and make them feel safe. Some clients 

will be dependant on others for their toileting needs, and may only be able to use the toilet at 

times of the day when a carer is present. Can clients undress to toilet themselves? 

State the patient’s hygiene status. Are they able to wash themselves? Is cleansing after 

toileting or episodes of incontinence an issue? 

Urinary Symptoms 

Given the wide variability with which symptoms have an impact on the patient’s quality of 

life, identification of the problems perceived by the patient including their most bothersome 

symptoms. Try to include specific words used by the patients/carers. Identify difficulties 

with sexual relationships, as this is extremely important in assisting patients to regain some of 

their self esteem. 

Dysuria 

Dysuria means pain or burning whilst passing urine. It is often caused by a urinary tract 

infection. If the patient indicates a history of Urinary Tract Infections (UTI’s), document if 

specific organisms have been identified, or if not. The frequency and treatment of UTI’s 

should also be noted. 

If the answers are “yes” to the assessment questions, ensure a urinalysis is obtained, and 

subsequent MSU if appropriate. 

Common causes: - poor hygiene, residual urine, poor fluid intake, atrophic vaginitis, and 

sexually transmitted diseases. 

7 


Stress Incontinence 

Is indicated by leakage of small amounts of urine upon physical exertion e.g. laughing, 

coughing and sneezing, and sometimes just on movement, It is often due to urethral 

sphincter incompetence due to weak pelvic floor muscles, intrinsic sphincter weakness or 

surgery. 

If this is indicated by “yes” answers to the assessment questions please follow the stress 

incontinence pathway. Use symptom profiles to help identify cause of incontinence. 

(Appendix 1a). 

Common Causes: Female Childbirth, constipation, obesity 

Male Radical Prostatectomy 

Urgency/Urge Incontinence. 

Is indicated by loss of large amounts of urine, with a desire to urgently void, there is also 

accompanying frequency of urine. It is primarily caused by an overactive bladder. When 

reviewing the frequency volume chart (Appendix 1b) a frequency of over 8 times a day may 

indicate bladder over activity. If the answers to these assessment questions are “yes” follow 

the urge pathway. If the client has a mixture of symptoms both stress and urge, follow both 

pathways. This may be done simultaneously or stress first. 

Common Causes: - bladder irritating drinks i.e. caffeinated tea, coffee, cocoa, fizzy drinks, 

orange and lemon drinks. Low fluid intake, detrusor instability, urinary tract infection, 

constipation, pregnancy, diabetes, and neurological conditions. 

Obstruction/Voiding Difficulties 

Lower urinary tract symptoms (L.U.T.S.) or feelings of incomplete emptying may result in 

symptoms of hesitancy, straining, frequency, poor flow, interrupted stream, and dribbling 

post void. Symptoms may be caused by an obstruction or an under active bladder. 

Common Causes: - enlarged prostate in men. Stricture, prolapse, constipation, diabetes 

neurological conditions and prolonged over distention of the bladder. 

If the answers to these questions are “Yes” follow the voiding dysfunction pathway. 

Reflex Incontinence 

Reflex incontinence is indicated by involuntary loss of urine. Leakage occurs in the absence 

of any desire to void, and as a result of a neurological problem. 

Common Causes: - spinal injury, congenital abnormality, neurological condition. 

If the answers to these questions are “Yes” follow the reflex incontinence pathway. 

8 


Functional Incontinence 

Occurs as a result of a medical condition outside the urinary tract, typically cognitive or 

physical impairment. 

Immobility or lack of dexterity may restrict the client’s ability to reach the toilet. 

Common Causes: - Dementia, Parkinson’s, CVA immobility, learning difficulties. If the 

answers to these questions are “Yes” follow the functional incontinence pathway. 

Nocturia 

Is getting up at night to pass water. It is important to distinguish whether the desire to void is 

the reason for waking, or whether the client is awake anyway. Getting up once or twice to 

void is common over the age of 50. Nocturnal polyuria is defined from the frequency volume 

chart as passing more than one third of the daily output overnight. Clients who spend a large 

proportion of the day in a sitting position have reduced blood flow to their kidneys. This 

resolves once lying down, and urine is produced more freely. 

Common Causes:- 

Nocturia: detrusor instability, residual urine, UTI, diurnal disturbance, prostatic enlargement. 

Treat the problem. 

Nocturnal Polyuria: heart failure, diabetes, pituitary tumour, postural oedema. 

If taking diuretics, alter time to 5 hours before bed. Elevate legs during the day 

Nocturnal Enuresis 

Night time incontinence without associated day time wetting can be identified as primary or 

secondary enuresis. 

Primary enuresis is when a child over the age of 7 has never been dry on a regular basis. 

Common Causes: - lack of antidiuretic hormone, deep sleep, or cognitive impairment. 

Secondary enuresis follows a significant period (12 months) of dryness. 

Common Causes: - psychological events, medication, alcohol/drug abuse, bladder instability. 

If the answers to these questions are Yes”, follow the enuresis care pathway. 

Fluids 

An accurate record of fluid intake, including type and amount is a vital part of the 

assessment. Ask to see the usual size cup or mug. Do they drink a full cup or half? Caffeine 

is a diuretic, and a bladder stimulant, which can exacerbate urgency. Alcohol and fizzy 

drinks will have a similar effect. (See Appendix 3) 

Many incontinent people use fluid retention to manage their incontinence. Concentrated 

urine can irritate the bladder and cause urothelial irritation. It will also eventually diminish 

bladder capacity, leading to frequency. For suggested fluid intake see Appendix 3. 

Common Causes: - Dementia, Parkinson’s CVA immobility, learning difficulties, learnt 

behaviour. 

9 


Food intake 

Document type of diet including fibre score. (See Appendix 4). Many people do not have 

sufficient fibre in the diet, which can result in constipation. Recommended daily intake is 30 

grams. General advice should be to eat 5 portions of fruit or veg. per day, and ensure 

adequate fluid intake. Care should be taken in the elderly and infirm to increase fibre slowly 

in order to prevent obstruction. Vegetarians may already have a high fibre intake and may be 

prone to constipation if their fluid intake is insufficient. 

Bowel Habit 

Identify the client’s normal bowel habit, including frequency and consistency. If bowels are 

known to be a problem prior to assessment send bowel habit diary for patient to complete. 

Use Bristol Stool Scale to document appearance. (See Appendix 4a). Identify any recent 

changes in bowel habit. E.g. bleeding, constipation without cause, diarrhoea, pain, colour of 

stool. Report changes to GP immediately. 

Faecal Incontinence 

Muscular. Incontinence of small amounts of solid stool, or gas is likely to be due to 

muscular weakness, commonly following surgery, or childbirth. 

Neurological. Leakage of normal stool with no awareness is usually due to neurological 

damage, either trauma or degeneration. 

Urge. Urgency of defaecation is likely to be associated with softer or liquid stool. Its may be 

related to diet, infection or inflammation or irritation of the bowel. 

Functional. Cognitive impairment may sometimes prevent the client being aware of the 

need to have their bowels opened. If they are unable to verbalise this need they may try to 

perform self-manual evacuations, if they become constipated. 

Overflow. Patients often become constipated so gradually that they forget that they have not 

had their bowels opened for a long time. When they start to leak faecal liquid they think that 

they have diarrhoea. 

If faecal incontinence is suspected, then follow the appropriate care pathway. 

Other Useful Information 

Include details of social support, care packages and frequency of care. Include information 

regarding the patient’s routine, e.g. trips to day care etc. If employed any other factors 

important to the patient which may have a bearing upon their continence. 

10 


Physical Examination 

Consent 

Document that the client has given their consent. If anyone else is present state who. If the 

client refuses consent do not proceed with the examination. 

Skin Condition 

Assess for soreness, excoriation, broken areas. When giving advice on cream, advise only a 

very thin layer of barrier cream if a pad is to be worn. Avoid oil based creams (see Appendix 

5). Cavilon does not clog pads or reduce their absorbency. 

Vaginal Examination 

External Examination-Assess for visible signs of prolapse (shown by external bulging of the 

vagina) refer to GP. 

Skin texture and colour – Atrophic vaginitis may be present following the menopause or 

hysterectomy. The vagina and surrounding tissue is pale, dry and the patient may report 

feeling sore and itchy. Request oestrogen cream or pessaries from GP. HRT is not required, 

local oestrogen is suitable. 

Visible leakage of urine on coughing - Follow stress incontinence care pathway. 

Internal examination – exclude latex sensitivities if using latex gloves, assess pelvic floor 

squeeze Oxford scale (See Appendix 1c). 

Abdominal Distension – Assess abdomen for constipation, abdominal distension. Anal 

condition. Visible skin changes. 

Investigations 

Frequency volume chart (Appendix 1b) 

Where possible, ask the client to fill this in themselves. There should be no reason why a 

Residential home patient cannot have a chart filled in. If wet, document the number of wet 

episodes. Document output, bowel movement and pad changes. The chart can then be used 

to plan a programme, and evaluate subsequent treatment and interventions. It can confirm or 

disprove the perceived problem. 

Urinalysis 

Urinalysis is an essential step in a continence assessment. The principle purpose being to 

exclude a urinary tract infection, which may be a temporary cause of incontinence. A MSU 

should be sent to the lab for culture if the dipstick is abnormal. 

11 


Post Void Residual Urine 

Post void residual (PVR) should be measure by intermittent catheterization, or by bladder 

scan. Any PVR predisposes the patient to infection or incontinence. Residual urine may be 

due to obstruction or poor bladder contractability. Less than 50 mls is considered normal and 

over 200 mls is abnormal (Fanti et al 1996). In routine clinical practice a raised PVR is 

significant if between 100 – 150 mls. If found, further investigations may be necessary. 

Knowledge of the PVR may have an impact on management e.g. anti cholinergic therapy can 

reduce bladder contractability and is contraindicated when PVR is high. 

Summary of Problem 

Document a summary of the problem. 

Possible Diagnosis 

This section is to be completed at the end of the assessment process. Care pathway(s) to be 

commenced. 

Review Dates 

State the planned review for the individual. If undergoing treatment this may be sooner if 

pads are to be provided. 

Planned Action 

Document planned action, advice given, if different form that stated on the care pathway. 

If you require more advice regarding the assessment for please 

contact your Continence Advisor telephone 0117 9677191 

12 


Continence Advisors – Hospital Contacts 

USEFUL CONTACT NUMBERS 

Frenchay/ Thornbury Hospitals - Jan Cotter 

Downend Clinic 

Tel: 0117 3302505 

Southmead Hospital - Mary Lou Brennan 

Lawrence Weston Clinic 

Tel: 0117 9829129 

University Hospital Bristol - 

(B.R.I.) Knowle Clinic 

Tel: 0117 9190226 

Weston General Hospital - Lyn Kirkwood 

01934 647149 

Continence Advisors – Community Contacts 

Bristol Community Health Office (North) Mary Lou Brennan 

Lawrence Weston Clinic 

Tel: 0117 9829129 

(South) Office - 

13 

Knowle Clinic 

Tel: 0117 9190226 

North Somerset PCT - Cath Williams 

Pill Health Clinic 

Tel: 01275 373104 or 

01934 881219 

NHS South Gloucestershire - Jan Cotter 


Tel: 0117 3302505 

Useful Contacts 

Bladder and Bowel Foundation:- Nurse Helpline: Tel: 0845 3450165 

Counsellor Helpline: Tel: 0870 7703246 

www.bladderandbowelfoundation.org 

ERIC: help for children, young people and their parents. Tel: 0117 9603060 www.eric.org.uk 

IBS Network: Tel: 0114 2723253 www.ibsnetwork.org.uk 

National Association for Colitis and Crohn’s Disease Tel: 0845 1302233 www.nacc.org.uk 


CONTINENCE ADVISORY SERVICE 


SGLOS PCT 

Buckingham Gardens 

Bristol 

BS16 5TW 

Tel: 0117 3302505 

CAS Philosophy CAS Service Aim 

Continence should be expected by all We work with clients to cure or improve their 

irrespective of: - bladder or bowel problems – in many cases 

they are curable. If this is not possible we will 

* age ensure effective management so that people 

* gender with this problem can have maximum quality 

* disability and dignity in their lives. 

ABOUT THE PEOPLE WE SERVE CAS Targets for Practice 

A service for people with bladder or bowel * Developing a working relationship with 

problems and their carers. our clients 

1 in 4 women have a bladder problem * Full accountability for care given to our 

at sometime in their life. clients 

1 in 10 men have a bladder problem * Providing a quality service through expert 

at sometime in their life. care 

1 in 200 people have a bowel problem. * Developing knowledge through research 

14 

* Involve clients and their carers in 

developing services to meet their needs 

YOU ARE NOT ALONE – 

CONTACT US FOR ADVICE 


URINE 

Record urinalysis on 

ALL 

patients on arrival. 

if +ve send 

MSU 

Is there a UTI? 

Yes – inform doctor 

Treat UTI & Reassess 

Assessing Continence – STEP 1 

Ask about any SYMPTOMS of URINARY or FAECAL 

INCONTINENCE 

Is the patient aware? Are they bothered by it? 

Is this a new or longstanding problem? 

Please inform the ward doctor. 

DEALING WITH 

FUNCTIONAL 

INCONTINENCE 

Check mobility and access to 

toilet 

Is regular toileting required? Look 

at the pattern of incontinence. 

Record times toileted (T) 

Are toileting aids required? 

(commode, bed pan) 

Consider sanitary protection as 

appropriate (sheath, pads) 

Only catheterise in accordance 

with guidelines. 

FLUIDS & FREQUENCY /VOLUME CHART 

15 

BOWELS 

Ascertain normal bowel habit 

Use a daily STOOL CHART 

(refer to the Bristol Stool 

Scale ) 

Examine rectum (PR) 

Is there any 

CONSTIPATION 

or OVERFLOW 

DIARRHOEA? 

Yes – inform doctor 

STOOL sample if diarrhoea 

Treat & Reassess 

Keep an accurate FLUID CHART. 

Ensure adequate daily FLUID INTAKE (according to weight and medical condition) 

Start a URINARY FREQUENCY/VOLUME CHART for 3 days (or pad weight) 

Is there any pattern to the urinary incontinence. 

MEDICAL ASSESSMENT 

Any relevant Past Medical, Surgical or Obstetric History 

REVIEW DRUGS 

EXAMINATION. 

Memory Test Score – Dementia? Stroke? Cord Compression? 

Cardiovascular – CCF? 

Palpate for a bladder – Retention? 

Pelvic floor – Prolapse, atrophic Vaginitis? PR. Anal tone, prostate and stool. 

If incontinence persists progress to STEP 2 


STEP 2 

Complete Continence Assessment & 

Complete Patient Symptom Profile 

Patient Symptom Profile 

Review Urinary frequency/flow chart 

Is there any patter to the urinary 

Consider checking bladder residual volume 

using 

Bladder scanner (or Ultrasound scan) 

or Urinary Flow Dynamics 

Aim to identify type of urinary incontinence. 

STRESS, URGE, OVERLOW or MIXED. 

Commence on relevant Care Pathway if appropriate. 

You may wish to liaise with Continence Team. 

For FAECAL INCONTINECE refer to the 

Faecal Incontinence Care Pathway. 

STEP 3 

If no improvement after 12 weeks. 

Refer to CONTINENCE TEAM or DOCTOR with a 

special interest, for further appropriate investigation 

and treatment 

Continence Team: 0117 9677191 

Adapted from Tool by: Dr R Bradley. RUH Bath November 2005 

16 


Please individualise pathways as necessary. Add names where appropriate, cross through 

interventions not required. Add additional interventions at the end as appropriate. All entries 

should be signed and dated. 

CONTINENCE CARE PATHWAY 1 - FEMALE STRESS INCONTINENCE 

Patient Name 

17 

Problem 

Goal: To help………………………………….. increase pelvic floor strength to be able to 

Prevent…………………………………………. leakages a day. 

Increase pelvic floor squeeze from ……………. to …………………… Oxford Scale 

Nursing Action/Intervention 

Continence Assessment Appendix 1 + 1a 

1. Teach Pelvic Floor Exercises (Appendix 6) 

…………………………………. has agreed to undertake 

…………………………………. contractions 

…………………………………. times per day 

2. If constipation is identified, follow pathway 

3. Discuss appropriate type and amount of fluid intake (Appendix 3/3a) 

4. Review after 8 – 12 weeks, reinforce need to do pelvic floor exercises 

regularly. 

5. Where appropriate, give advice about buying products. 

6. If no improvement after 8 – 12 weeks consider referral to Continence 

Advisor. Date of referral: 

7. On discharge, provide an opportunity to discuss treatment outcomes in 

relation to identified goals. 

8. State why this care pathway has not been successful for this patient. 

9. Other interventions 

Start date: Signed: Print Name: Position: 

Review 

date 


CONTINENCE CARE PATHWAY 1 

Standard Statement 

FEMALE STRESS INCONTINENCE 

All female clients with stress incontinence will undergo the following nursing interventions. 

1. Continence Assessment Appendix 1, paying specific attention to obstetric history, 

urinalysis and bowel assessment. 

2. External vaginal assessment to assess for atrophic vaginitis, other inflammatory 

conditions, visible leaking on coughing 

3. Internal vaginal examination by competent person to assess pelvic floor strength and 

ability. Any observed abnormalities, refer to GP. 

4. Explain and teach pelvic floor exercises and confirm the patient understands. Provide 

information sheet (Appendix6) 

Review progress after 12 weeks 

Improvement No Improvement 

Review in 4 weeks 

Improvement 

Reinforce advice and continue exercises 

18 


No improvement 

Refer to Continence Advisor 

Patient Satisfied Consider biofeedback 

Discharge 

Evaluation Date/time Date/signature 

Refer to Urogynaecologist 





CONTINENCE CARE PATHWAY 1a - MALE STRESS INCONTINENCE 

Patient Name 

19 

Problem 

Goal: To help………………………………….. increase pelvic floor strength to be able to 

Prevent…………………………………………. leakages a day. 


Continence Assessment Appendix 1 + 1a 

1. Bladder scan to rule out overflow. If overflow is present refer to GP for 

Urology referral. 

2. Teach Pelvic Floor Exercises (Appendix 6a) 

…………………………………. has agreed to undertake 

…………………………………. contractions 

…………………………………. times per day 

1. If constipation is identified, follow pathway 

2. Discuss appropriate type and amount of fluid intake (Appendix 3/3a) 

3. Review after 12 weeks. Reinforce need to pelvic floor exercises regularly. 

4. Where appropriate, give advice about buying products. 

5. If no improvement after 12 weeks consider referral to Continence 

Advisor. Date of referral: 




8. Other interventions 


Review 

date 


CONTINENCE CARE PATHWAY 1a 

STANDARD STATEMENT 

MALE STRESS INCONTINENCE 

All male clients with stress incontinence will undergo the following nursing intervention. 

1. Continence assessment Appendix 1, paying specific attention to urological history. 

2. Bladder scan to rule out retention or under active bladder. Residual urine greater than 150 

mls, or causing significant stress leakage, refer to GP 

3. Explain and teach pelvic floor exercises and confirm the patient understands (Appendix 

6a) 

Review progress after 12 weeks. 


Reinforce advice and continue exercises 


Improvement 

No improvement 


Patient Satisfied No improvement 

Discharge Refer to Urologist 


20 





CONTINENCE CARE PATHWAY 2 - FREQUENCY, URGENCY AND 

URGE INCONTINENCE 

Detrusor Overactive (bladder) 

Patient Name 

21 

Problem 

Goal: To help………………………………achieve a normal bladder voiding pattern. This 

means being able to hold on comfortably for ……………… hours between going to the toilet. 


Continence Assessment Appendix 1 + 1a + 1b 

Bladder scan to rule out overflow. If overflow refer to GP for urology referral. 

1. Fluids: discuss appropriate type and amount of fluid intake. If appropriate, 

give caffeine leaflet (Appendix 3), and fluid intake leaflet (Appendix 3a). 

…………………………………………. has agreed to drink 

………………………………………….. cups/mugs per day 

Decrease caffeine drinks by …………… per day 

2. If constipation is identified, follow pathway. 

3. Teach Pelvic floor exercises (Appendix 6). Follow continence care 

pathway 1. 

4. Treat other possible causes of urgency, e.g. Urinary infection, vaginitis, 

diabetes 

5. Start bladder retraining programme. (See Appendix 7). Include full 

explanation of bladder retraining programme. 

6. Where appropriate, give advice about products. (Appendix 9) 

7. In no improvement after 8 – 12 weeks reinforce exercise programme. 

Consider anti cholinergic drug therapy. 

8. If no improvement after 12 weeks discuss provision of products for 

management of problem or refer to Continence Advisor (Appendix 9) 



10. State why care pathway has not been successful for this patient. 

11. Other interventions. 


Review 

date 




FREQUENCY AND URGENCY 

All patients with urgency and/or frequency will undergo the following nursing interventions. 

1. Continence assessment Appendix 1, including a frequency volume chart Appendix 1c, and 

documentation of fluid intake. Exclude residual urine (150 mls) 

2. Urinalysis to identify urinary tract infection (Subsequent MSU and treat where necessary). 

3. (Female) Pelvic floor examination. If muscle weakness is identified also follow pathway 

1a 

4. Discuss fluid intake, decrease caffeine if appropriate. 

If voiding over 8 times a day, and on no medication which is responsible (i.e. diuretics) 

commence on bladder retraining programme Appendix 7. 

Review after 12 weeks. 


Reinforce exercise programme Consider anti cholinergic 

therapy 



Patient Satisfied Discuss with Continence Advisor re 

product provision 

Discharge 


22 

Consider neuro muscular stimulation therapy 






CONTINENCE CARE PATHWAY 3 - VOIDING DIFFICULTIES 

Patient Name 

23 

Problem 

Goal: To help……………………………… empty their bladder completely, reducing the 

residual urine to below 100 mls or an acceptable amount, which is not significant to the total 

bladder capacity, and is not impairing their continence. 


1. Complete Continence Assessment (Appendix 1), Appendix 1a Appendix 

1b and 1-PSS Score (men) Appendix 8, frequency volume chart recording 

normal voiding patter (times, amount of urine passed, episodes of 

incontinence) and fluid intake for 3 days 

2. Treat any identified urinary tract infection 

3. Resolve any identified constipation (Follow pathway 7) 

4. Record residual urine. (N.N. If abdomen is visibly swollen, urine can be 

seen continually dripping, or client is very uncomfortable do not wait for 

bladder scan. Perform residual catheterization) 

Date requested ……………………………….. 

5. Presumed bladder outlet obstruction 

- Refer to GP to refer on (Urology, Gynaecology if prolapse) 

Indwelling catheter if needed 

- Refer to Continence Service to teach Intermittent catheterization if 

appropriate 

6. Presumed detrusor weakness/failure 

Voiding techniques to stimulate bladder emptying (Double void, bladder 

stimulator) 

Refer to Continence Service (For Intermittent Catheterisation or 

consideration for urodynamics) 

Indwelling catheter is needed 






Review 

date 




VOIDING DIFFICULTIES 

All patients with voiding difficulties will undergo the following nursing interventions. 

1. Continence assessment Appendix 1, which identifies symptoms of voiding difficulties, 

Appendix 8 including a frequency volume chart (Appendix 1b). 

2. Urinalysis to identify urinary tract infection (Subsequent MSU & treat where necessary) 

3. Assess for and treat constipation. 

4. Residual urine greater than 50 mls, or causing significant discomfort or leakage. 

Presumed Detrusor Failure Presumed Outlet Obstruction 

Double voiding Refer to GP for onward referral :- 

Female- Gynae, if prolapse 

Refer to Continence/Urology Services Male - Urology 

For ISC/Urodynamic Studies 

Indwelling catheter inserted if required Indwelling catheter inserted if required 


24 





CONTINENCE CARE PATHWAY 4 - REFLEX INCONTINENCE 

Patient Name 

25 

Problem 

Goal: To ensure that ……………………………… is able to remain continent, by using the 

following care strategies. 


1. Complete continence assessment Appendix 1, paying particular attention to 

urinalysis and constipation. 

2. Complete a frequency/volume chart Appendix 1b recording client’s normal 

voiding pattern (times, amount of urine passed, and episodes of 

incontinence) and fluid intake for 3 days. 

3. Exclude residual urine. 

Date requested …………………………….. 

4. Plan a programme of toileting based upon the voiding patterns identified 

on frequency/volume charts. Programme is based upon toileting every 

……………………………………………… 

5. Review in 4 weeks. 

Adjust the time intervals between going to the toilet up and down to ensure 

dryness. Programme is based on toileting every ………………………….. 

6. Provide products for management of problem. e.g. sheath, incontinence 

pads (max per 24 hours) Refer appendix 9 






Review 

date 




REFLEX INCONTINENCE 


1. Continence assessment Appendix 1, paying specific attention to urinalysis, constipation, 

residual urine, and bladder sensation. If there is a post-void residual urine of more that 

150 mls follow the voiding difficulties pathway (Pathway 3) 

2. Frequency volume chart identifying patient’s normal voiding pattern.(Appendix 1b) 

3. Plan a programme of toileting based upon voiding patterns identified. 

Review in 4 weeks. 

Adjust time to achieve dryness. 

Suggest products to achieve social continence (e.g. pads 3 max per day, sheath, washable 

products which may be purchased) (Appendix 9). 

Improvement No improvement 

Continent Discuss with Continence Advisor 

Discharge Consider medication 

26 

Consider Management Options 






CONTINENCE CARE PATHWAY 5 - FUNCTIONAL INCONTINENCE 

COGNITIVE PROBLEMS 

Patient Name 

27 

Problem 




1. Complete continence assessment Appendix 1, paying particular attention to 

urinalysis and constipation. 

2. Complete a frequency/volume chart Appendix 1b recording client’s normal 

voiding pattern (times, amount of urine passed, and episodes of 

incontinence) for 3 days. 

3. Plan a programme of toileting based upon the voiding patterns identified 

on frequency/volume charts. Programme is based upon toileting every 

…………………………………………….. 

4. If undertaking prompted toileting Appendix 10 please give 

…………………… praise when toileting is successful and if they are 

found to be dry on checking. Complete frequency/volume chart for 3 days 

prior to review. 

5. Review in 1 week. 

Adjust the time intervals between going to the toilet to ensure dryness. 

Programme is based on toileting every ………………………………. 

6. When undertaking prompted toileting continue with positive reinforcement 

and praise. (A prompt is a kind of social support. If it is removed too 

quickly, the response will break down; therefore prompts should be 

withdrawn gradually). 

7. Provide products for management of problem if necessary. E.g. sheath, 

incontinence pads (max 3 per 24 hours) (Appendix 9). 






Review 

date 




FUNCTIONAL INCONTINENCE COGNITIVE PROBLEMS 


1. Continence assessment Appendix 1, which rules out other types of incontinence and 

identifies functional incontinence due to cognitive impairment. 

2. Complete a frequency volume chart Appendix 1b recording patient’s normal voiding 

pattern (times, volume passed, and episodes of incontinence). 

3. Identify appropriate toileting programme. (Appendix 10) 

Develop a set of toileting times based on patient’s voiding pattern. Adjust time 

intervals to achieve dryness. Give client praise and positive reinforcement when 

toileting is successful or they are dry. 



Continue with programme Discuss with Continence Advisor 

28 

Provide products 






CONTINENCE CARE PATHWAY 5a - FUNCTIONAL INCONTINENCE 

MOBILITY/DEXTERITY PROBLEMS 

Patient Name 

29 

Problem 




1. Complete continence assessment Appendix 1, paying particular 

attention to urinalysis and constipation. 

2. Complete a frequency/volume Appendix 1b chart recording client’s 

normal voiding pattern (times, amount of urine passed, and episodes of 

incontinence) for 3 days. 

3. Plan a programme of toileting Appendix 10 based upon the voiding 

patterns identified on frequency/volume charts. Programme is based 

upon toileting every ………………………………………………….. 

4. Liaise with carers re times of toileting if assistance is requied. 

5. Where necessary refer to OT or Physio for further assessment. 

6. Review in 4 weeks. 

7. Where necessary refer to Continence Advisor for advice re specialist 

toileting aids. 

8. Provide products for management of problem if necessary, e.g. 

catheter, sheath, incontinence pads (max 3 per 24 hours). (Appendix 9) 






Review 

date 




FUNCTIONAL INCONTINENCE MOBILITY/DEXTERITY PROBLEMS 


1. Continence assessment Appendix 1, which rules out other types of incontinence and 

identifies functional incontinence due to immobility or poor dexterity. 

2. Complete a frequency volume chart Appendix 1b recording patient’s normal voiding 

pattern (times, volume passed, and episodes of incontinence). 

3. Where appropriate refer to O/T Physio for advice on aids/mobility. 

4. Identify appropriate toileting programme. Appendix 10. 

Liaise with carers to arrange appropriate times for assisted voiding. Adjust time intervals 

to achieve dryness. 



Discharge Discuss with Continence Advisor re: 

specialist toileting aids and 

product provision 

30 

Consider Refer to Continence Advisor 

For neuro muscular stimulation 

therapy 






CONTINENCE CARE PATHWAY 6 - NOCTURIA 

Patient Name 

31 

Problem 

Goal: To help ……………………………… achieve a appropriate night time bladder pattern. 

This means trying to reduced the number of voids overnight. 


1. Continence Assessment (Appendix 1) Fluids: discuss appropriate type and 

amount of fluid intake. (Appendix 3 & 3A). If appropriate, give fluid 

leaflets. …………………………. has agreed to drink 

…………………………………………. cups/mugs per day 

decrease caffeine drinks by …………………………per day 

2. Identify medication that may increase nocturnal voiding or prevent waking 

to use the toilet. (Appendix 2). 

3. Check medical history to ensure no history of heart disease contributing to 

nocturnal voiding. Look for signs of oedema. 

4. Assess frequency/volume chart Appendix 1b. If total urine output 

overnight is greater that 1/3 total daily output request diuretic drugs (e.g. 

Frusemide) from GP to be given 6 hours before bedtime. 

5. Assess mobility and dexterity function to ensure that toilet access 

overnight is not a causative factor. Follow function care pathway 5a. 

6. If no improvement after 4 weeks consider referral to Continence Advisor. 

7. Provide products for management of problem if necessary, e.g. sheath, 

incontinence pads (max one overnight) or toileting aids. (Appendix 9) 

8. On discharge, provide and opportunity to discuss treatment outcomes in 





Review 

date 




NOCTURIA 

All patients with nocturia will undergo the following nursing interventions. 

1. Continence assessment Appendix 1, paying specific attention to frequency volume chart 

Appendix 1b and fluid intake. 

2. If frequency/volume chart Appendix 1b shows a daytime problem as well, follow urge 

pathway. 

3. Check medication Appendix 2, and medical history to rule out heart disease. 

4. If over 1/3 of total urine output is produced at night, request evening diuretic from GP (e.g. 

Frusemide 5-6 hours before bedtime). 

5. Assess functional ability. If this prevents the patient getting out of bed at night follow 

pathway 5a, as well. 

6. Give advice about bed protection. (Appendix 9) 



Continue Continue 

Improvement 

Review at 8 weeks 

32 


Discharge 






CONTINENCE CARE PATHWAY 6a – NOCTURNAL ENURESIS 

Patient Name 

33 

Problem 

Goal: To help ……………………………… achieve a appropriate night time bladder pattern. 

This means trying to reduced the number of voids overnight. 


Complete Continence Assessment (Appendix 1) 

1. Fluids: discuss appropriate type and amount of fluid intake Appendix 1b. 

If appropriate, give fluid leaflets. …………………………. has agreed to 

drink 



2. Identify medication Appendix 2 that may increase nocturnal voiding or 

prevent waking to use the toilet, including over the counter, recreational 

and alcohol. 

3. Check medical history to ensure no history of heart disease contributing to 

nocturnal voiding. Look for signs of oedema. 

4. Assess frequency/volume chart Appendix 1b. If total urine output 

overnight is greater that 1/3 total daily output request diuretic drugs (e.g. 

Frusemide) from GP to be given 6 hours before bedtime. 

5. Assess mobility and dexterity function to ensure that toilet access 

overnight is not a causative factor. Follow function care pathway 5a. 

6. Give advice regarding bedding protection. (Appendix 9). 

7. If no improvement after 4 weeks consider referral to Continence Advisor. 




10. Other interventions ie. use of Desmopressin. 


Review 

date 




NOCTURNAL ENURESIS 

All patients with nocturia will undergo the following nursing interventions. 

1. Continence assessment Appendix 1, paying specific attention to urinalysis. (If positive to 

protein, blood, leucocytes or nitrates send MSU then treat) and fluid intake. 

2. If frequency/volume chart Appendix 1b shows a daytime problem as well follow pathway 

2. 

3. Check medication, (prescribed, over the counter, herbal and recreational), and alcohol 

consumption to ensure this is not causing the problem, or preventing waking. 

4. Assess functional ability. If this prevents the patient getting out of bed at night follow 

pathway 5a. 

5. Give advice about purchasing bed protection. (Appendix 9). 

6. If patient has primary enuresis (never had dry nights) and is under 60 years, and has no 

other medical problems, consider Desmopression, liaise with GP. 



Continue Continue 

Review at 8 weeks 


Discharge Refer on: 

Adults to Continence Advisor 

Children to Enuresis Clinic 


34 





CONTINENCE CARE PATHWAY 7 – CONSTIPATION 

Patient Name 

35 

Problem 

Goal: To help ……………………………… open their bowels regularly, and painlessly, 

according to an appropriate pattern i.e. bowel action every …………………… days 


1. Continence Assessment Appendix 1 and frequency/volume chart Appendix 

1b including bowel diary Appendix 4c to be completed 

2. Fluids: discuss appropriate type and amount of fluid intake. If appropriate, 

give fluid leaflets. (Appendix 3 + 3a) 

…………………………. has agreed to drink 



3. Ensure that there are no signs of obstruction(vomiting, pain, distended 

abdomen, absent bowel sound). If present, refer to GP urgently. 

4. Give dietary advice, ensuring that ……………………… is having a fibre 

rich diet. Use appendix 4, fibre score sheet. 

5. Give advice on exercise. Moving limbs will help prevent constipation. 

Refer to Physio if appropriate. 

6. Give advice on correct toilet positioning, see page 47. Refer to OT is 

appropriate. 

7. Commence laxatives as per local policy. 

8. Review laxatives after 5 days. Discontinue or put on maintenance course 

if ……………………….. is opening their bowels regularly and stool type 

4/5 on the Bristol Stool Scale. Appendix 4a. 





Review 

date 




CONSTIPATION 

All patients with constipation/faecal leakage will undergo the following nursing interventions. 

1. Continence assessment Appendix 1, paying specific attention to bowel diary Appendix 4c, 

fluid intake and medication. 

2. Rectal examination to exclude impaction with overflow refers to local policy (DRE 

training competent person) 

3. Any patient with signs of obstruction will be referred to GP urgently. 

4. Advice regarding correct amount of fibre and fluid intake needed, using fibre score sheet, 

and fluid matrix. Appendix 3a and 4. 

5. Pathway 5 or 5a also to be followed if appropriate. 

6. If no other cause, send stool sample for microbiology. 



Continue Increase medication 

Review after 4 weeks 


Discuss with GP/ 

Continue Continence Advisor 

Provide pads 


36 


Client Name 

Address 

Post Code 

Telephone Number 

NHS South Gloucestershire 

Community Continence Assessment Tool 

To be completed in consultation with the client whenever possible 

Bristol and Weston Continence Partnership 

37 

Date of Birth 

Name of GP 

GP Address 

Date of Assessment 

Name of Assessor - 

Base 

NHS Number 

How does the client feel about their continence problem? How does it affect them?............................................................................ 

.................................................................................................................................................................................... 

................................ 

Date of Onset and Description of Presenting Problems, include any relevant history 

.................................................................................................................................................................................... 

.................................................................................................................................................................................... 

……………………………………………………………………………………………………………………… 

……………………………………………………………………………………………………………………… 

……………………………………………………………………………………………………………………… 

Relevant Health History (please state or tick) 

Weight................................................................................... Cystoscopy?................... Back Problems?...................................... 

Obstetric History.................................................................. Diabetes?........................ Spinal Injury?........................................ 

Difficult Deliveries?............................................................. CVA?............................ Dementia.?............................................. 

Bowel Surgery? ................................................................... MS.?................................. Learning Disability.?.............................. 

Hysterectomy?..................................................................... Parkinson’s..................... Psychiatric History?............................. 

Previous Repair Surgery? ................................................... Depression?................... 

Prostatectomy? ........................................................ Constipation?................. 

Other?.................................................................................................................................................................. 

CVA?................................................................................... Bladder Surgery?........... 

Current Management (please tick) 

Toileting Routine Sheath Pants 

Pads Catheter Supra Pubic catheter 

Appendix 1 

Other Comments ie. Previous Investigations............................................................................................................................................. 

.................................................................................................................................................................................... 

............................... 

Name and Number of Pads if used……………………………………………………………………………………………………….. 

Other ....................................................................................................................................................................................................... 

Mobility to Independently Mobile Mobile with Carer Mobile with Aid .Mobile with Aid and Carer 

Toilet or 

Commode Transfers with carers Transfers with Standaid Transfers with Hoist Other..................................... 

Dexterity 

Able to manage clothes quickly and easily?.............................................................................................................................................. 

Describe any help needed with clothes/continence………………………………………………………………………………………. 


Current Medication 

...................................................................... 

........................................................... 

........................................................... 

........................................................... 

........................................................... 

........................................................... 

........................................................... 

........................................................... 

........................................................... 

........................................................... 

........................................................... 

........................................................... 

........................................................... 

Urinalysis 

Nitrate 

Ketones 

Blood 

Protein 

Leucocytes 

PH 

Glucose 

Dysuria?.................................................... 

If leucocytes/nitrate present or symptoms 

of UTI send MSU. Suspend assessment 

until treatment is completed. 

MSU Sent?..............Date.......................... 

Fluid Intake 

Cold drinks in 24 hours 

=…………. 

Drinks of Tea/ Coffee/Chocolate 

..................... cups/mugs in 24 

hours. 

8-10 cups/glasses of fluid daily are 

recommended. Drinks containing 

caffeine and alcohol (especially at 

night) may increase incontinence. 

Advice given on fluid 

intake?............. 

Faecal Incontinence YES / NO Frequency of Incontinence Daily Weekly Occasional 

Bowel Habit Daily Alternate Days Less Often Consistency of Stool (Bristol Stool Chart) Type ................. 

Bowel Management Programme? YES / NO Laxatives? YES / NO Enema/Suppositories YES / NO Frequency...................... 

Physical Examination – Full Explanation must be given to client and consent gained 

Please refer to Consent Policy/Mental Capacity Act Policy 

Able to Give Consent? YES/NO Consent Given? YES/NO 

Observation of Vaginal and Urethral Area YES / NO 

Comments................................................................................................................................................................................................ 

Atrophic Vaginitis? (Dryness, Paleness, Itchiness of surrounding tissues) YES / NO Comments......................................................... 

Signs of Prolapse YES / NO Comments.................................................................................................................................................. 

If signs of untreated constipation refer to GP YES / NO Comments...................................................................................................... 

Bladder Scan result =………………………………………………………………………………………………………………….. 

SKIN CONDITION Intact YES / NO Redness/Inflammation YES / NO 

Creams/ Barrier Preparations? YES / NO Please State............................................................................................................. 

ASSESSMENT OUTCOME 

Referral Required for further Investigations YES / NO Details........................................................................................................... 

Cause of Problem Stress Urge Overflow Intractable 

Plan of Care: Pelvic Floor Exercises Toilet Training? Pads Sheath 

Urethral Catheter Supra Pubic Catheter 

Other............................................................................ 

The following Care Pathways are available: Stress, Urge, Overflow and Bowel Incontinence and these should be followed whenever possible. 

Date............................................... Signature.........................................................Base…………………. 

Print Name in full ……………………………………………………………………………………………. 

38 


Stress Care Pathway 

Symptom Profile 

I leak when I laugh, cough, sneeze, run or jump YES/NO 

I only ever leak a little urine YES/NO 

At night I only use the toilet once or not at all YES/NO 

I always know when I have leaked YES/NO 

39 

Appendix 1a 

Leak without feeling the need to empty my bladder YES/NO 

Only my pants get wet when I leak (not outer clothing) YES/NO 

or I sometimes use panty liners 

Overactive Bladder Care Pathway 

I feel a sudden strong urge to pass urine and have to go quickly YES/NO 

I feel a strong uncontrolled need to pass urine prior to leaking YES/NO 

I leak moderate or large amounts of urine before I reach the toilet YES/NO 

I feel that I pass urine frequently YES/NO 

I get up at night to pass urine at least twice YES/NO 

I think I had bladder problems as a child YES/NO 

Voiding Difficulties Care Pathway 

I find it hard to pass urine YES/NO 

I have to push or strain to pass urine YES/NO 

My urine flow stops and starts several times YES/NO 

My urine stream is weaker and slower that it used to be YES/NO 

I feel it takes me a long time to empty my bladder YES/NO 

I feel as if my bladder is not completely empty after I have passed urine YES/NO 

I leak a few drops of urine on to my underwear just after I have passed urine YES/NO 


40 

Appendix 1b 


Grading System for Pelvic Floor Strength 

Pelvic Floor Activity 

No activity 

Flicker 

Weak contraction 

Fair contraction 

Good contraction 

Strong contraction 

THE OXFORD SCALE 

41 

Score 

0 

1 

2 

3 

4 

5 

Appendix 1C 


DRUG 

DRUGS AFFECTING BLADDER FUNCTION 

USE EFFECT 

42 

Appendix 2 

Alcohol Social Increased urinary frequency 

Increased urinary output 

Anticholiestrase Myastheinia Gravis 

Irritable Bowel Syndrome 

Antimuscarinics 

Anticholinergics 

Antimuscarinic Side effects 

I.e. Pizotifen/Promethazine 

Calcium Channel Blockers 

I.e. Nifedipine 

Cytotoxics 

Ie.Cyclophosphamide 

Ifosfamide 

Sphincter relaxation causing 

involuntary loss of urine. 

Contraction of smooth muscle 

Increased peristalsis 

Parkinson’s Disease Increase sphincter tone 

Decreases bladder 

contractibility 

May cause urinary retention 

Allergies i.e. 

Hay Fever/Rash/Migraine 

Angina/Arrythmias 

Hypertension 

As above 

Nocturia 

Increased frequency 

Malignancies Haemhorragic cystitis 

Diuretics Heart Failure Increased urinary output 

Opiate analgesics 

Ie.Morphine/Diamorphine 

Xanthines 

Ie.Theophylline/Caffeine 

Pain control 

Abuse 

Asthma 

Stimulant 

Bladder sphincter spasm and 

voiding difficulties 

Urge incontinence 

Diuresis 

Reference: Wells M. Development of urinary continence and causes of incontinence. 

In Norton C. 1996. Nursing for Continence Textbook. Beaconsfield Publishers. 


CAFFEINE 

43 

Appendix 3 

Caffeine is a natural drug that stimulates the body. It can act upon the central nervous system, 

heart muscle and lungs. It is a diuretic (it makes you produce more urine). Caffeine tightens the 

blood vessels and can worsen the effects of migraine type headaches. Caffeine may affect fertility 

and osteoporosis. For some people caffeine is also an irritant to the bladder. 

It has been considered that the average person should not take more than 300 mgs of caffeine per 

day. The following table shows the amounts per serving in various foods and drinks. 

Food/drink Caffeine per serving 

Fresh coffee 80-150 mgs 

Instant coffee 65-100mgs 

Tea 30-70 mgs 

Instant tea 30 mgs 

Coca Cola 45.6 mgs 

Diet Coke 45.6 mgs 

Pepsi Cola 37.2 mgs 

Diet Pepsi 37.2 mgs 

Dr Pepper 39.6 mgs 

Red Bull 80 mgs per 250 mls 

Chocolate bar (1 oz) 15 mgs 

Some cold relief tablets 30 mgs 

Drinking chocolate (3 heaped teaspoons 8 mgs 

Caffeine can be addictive in nature and people can experience withdrawal effects when reducing 

their caffeine intake. It is therefore vital that someone wishing to reduce their caffeine intake does 

so by cutting down gradually, i.e. by reducing 1 cup per day. 

Alternatives to caffeine drinks 

Herbal tea, e.g. peppermint, chamomile 

Fruit tea, e.g. orange, blackcurrant 

Fruit squash i.e. blackcurrant 

Avoid lemonade, Cranberry juice, and other fizzy drinks which may also cause bladder irritation. 


FLUID INTAKE 

MATRIX TO DETERMINE SUGGESTED 

VOLUME INTAKE PER 24 HOURS 

44 

Appendix 3a 

Note; This matrix is to be used as a guideline. It is suggested that patients fall within a 

margin of error of =/- 10%. 

This guideline applies to body frame and gross obesity should not be taken as a guide for 

increasing fluid intake. Activity levels should also be taken into account. 

Patients Weight Mls Fluid Ozs Pints Mugs 

38kgs 

(6 stone) 

1,190 42 2.1 4 

45Kgs 

(7stone) 

51Kgs 

(8 stone) 

57Kgs 

(9 stone) 

64Kgs 

(10 stone) 

70Kgs 

(11 stone) 

76Kgs 

(12 stone) 

83Kgs 

(13 stone) 

89Kgs 

(14 stone) 

95Kgs 

(15 stone) 

102Kgs 

(16 stone) 

1,275 49 2.5 5 

1,446 56 2.75 5-6 

1,786 63 3.1 6 

1,981 70 3.5 7 

2,179 77 3.75 7-8 

2,377 84 4.2 8 

2,575 91 4.5 9 

2,773 98 4.9 10 

2,971 105 5.25 10-11 

3,136 112 5.5 11 

Reference: Abrams & Klevmar 1996. Frequency Volume Charts – an indispensable part of 

lower urinary tract assessment. Scandinavian Journal of Neurology. 179; 57-53. 


FIBRE SCORING SHEET 

Score your diet for fibre content 

45 

Appendix 4 

Food 1 2 3 Score 

Bread White Brown Whole meal 

Granary 

Breakfast cereal Never or rarely 

eaten 

Potatoes 

Pasta 

Rice 

Pulses 

Beans 

Nuts 

Never or rarely 

eaten 

Less than once a 

week 

Vegetables Less than once a 

week 

Fruit Less than once a 

week 

Total Score = 

Score Guide 

0-12 Increase daily fibre intake 

13-17 Good fibre intake 

18+ Excellent fibre intake 

Corn Flakes 

Rice Crispies 

Cheerios 

Special K 

Eaten 3 Times a 

week or more 

Potatoes 

White Rice 

Pasta 

Eaten most days 

Once a week or 

less 

Bran Flakes 

Weetabix 

Shredded Wheat 

Muesli 

Shreddies 

Eaten 3 Times a 

week or more 

Jacket Potatoes 

Brown Rice 

Pasta 

Eaten most days 

Three times a 

week or more 

1-3 times a week Daily 

1-3 times a week Daily 


THE BRISTOL STOOL CHART 

46 

Appendix 4a 


Did you know? 

LOOKING AFTER YOUR BOWELS 

47 

Appendix 4b 

• Drinking the correct amount of fluid for your body weight (Appendix 3a) can help 

prevent constipation. The job of the last part of the bowel is to absorb fluid back into 

the body. It will do this even if you are drinking very little. If you are not drinking 

enough it makes the waste hard and difficult to pass. Fluid helps the waste remain 

slippery and therefore easier to pass. 

You need to drink___________________mugs/cups of fluid per day. 

• It is important that your diet has enough fibre. The best advice is to eat FIVE portions 

of fruit and vegetables a day. Your Nurse has a useful fibre scoring sheet (Appendix 

4) for you to assess how much you are really eating. 

My Fibre Score is____________________ 

If I need to improve my daily fibre intake I need to eat:- 

________________________________________________________________ 

________________________________________________________________ 

• Regular Exercise, within your limitations can stimulate the bowel to work regularly. 

• It is important to be sat in a good position to have your bowels open. You need to be 

well supported, with your feet on the floor (or stool), not slipping, sliding or having 

trouble getting on or off the toilet. 

Your Nurse can assess for toileting adaptations. 

• Bowels benefit from routine. Allow yourself time and privacy to empty your bowels. 

This can be difficult if you need help to the toilet. 

Discuss this with your Nurse-they may have ideas to help you. 

• When you feel the need to empty your bowel-respond! If you keep ignoring the need to go 

you can make yourself constipated. 

• Some medication may upset your bowel habit. Do not stop your medication. There may 

also be medication to regulate your bowel. 

Discuss this with your Doctor, Nurse or Chemist. 


Day/Date 

Time 

Hard/Soft 

Stool 

BOWEL HABIT DIARY 

What happens when you go to the toilet? 

Bristol 

Stool Score 

Accident 

Yes/No 

48 

Did you 

want to 

go? 

Yes/No 

Soiling 

Yes/No 

Appendix 4c 

Any other 

comments 

i.e. 

Laxatives 

used 


49 

Appendix 4d 


BARRIER PREPARATIONS 

50 

Appendix 5 

The following water based preparations are suitable for patients using continence pads either for 

urinary or faecal problems:- 

• Almond Oil 

• Aveeno Cream 

• Balneum Bath 

• Bepanthol 

• Cavilon 

• Clinisan 

• Dermamist 

• Drapolene 

• E45 cream or wash 

• Eucerin lotion 

• Hydromol cream or emollient 

• Intrasite Gel 

• LBF no sting skin barrier from Clinimed 

The following oil based preparations should be avoided as they stop the pads from absorbing:- 

• Aquaform 

• Asda nappy cream 

• Baby lotion 

• Connotrane 

• Granugel 

• Purilon 

• Sprilon 

• Sterigel 

• Sudocrem 

• Unguentum 

• Vaseline 

• Zinc and Castor Oil 


Pelvic Floor Exercises. 

Introduction. 

Physiotherapists, Doctors and Nurses know that pelvic 

floor exercises can help you to improve your bladder control. 

When done correctly, pelvic floor exercises can build up and 

strengthen the muscles to help you to hold urine. 

51 

Appendix 6 

What is the Pelvic Floor? 

Layers of muscle stretch like a hammock from the pubic bone in 

front to the bottom of the backbone (see diagram). These firm 

supportive muscles are called the pelvic floor. They help to hold the bladder, womb and bowel in 

place, and to close the bladder outlet and back passage. 

How Does the Pelvic Floor Work? 

The muscles of the pelvic floor are kept firm and slightly tense to stop leakage of urine from the 

bladder or faeces from the bowel. When you pass water or have a bowel motion the pelvic floor 

muscles relax. Afterwards, they tighten again to restore control. 

Pelvic floor muscles can become weak and sag because of childbirth, lack of exercise, the change 

of life, or just getting older. Weak muscles give you less control, and you may leak urine, 

especially with exercise or when you cough, sneeze or laugh. 

How Can Pelvic Floor Exercises Help? 

Pelvic floor exercises can strengthen these muscles so that they once again give support. This will 

improve your bladder control and improve or stop leakage of urine. Like any other muscles in the 

body, the more you use and exercise them, the stronger the pelvic floor will be. 

Learning to do Pelvic Floor Exercises. 

It is important to learn to do the exercise in the right way, and to check from time to time that you 

are still doing them correctly. 

1. Sit comfortably with your knees slightly apart. Now imagine you are trying to stop 

yourself passing wind from the bowel. To do this you must squeeze the muscle around 

the back passage. Try squeezing and lifting that muscle as if you really do have wind. 

You should be able to feel the muscle move. Your buttocks and legs should not move 

at all. You should be aware of the skin around the back passage tightening and being 

pulled up and away from your chair. Really try to feel this. 

2. Now imagine you are sitting on the toilet passing urine. Picture yourself trying to stop 

the stream of urine. Really try to stop it. Try doing that now as you are reading this. 

You should be using the same group of muscles that you used before, but don’t be 

surprised if you find this harder than exercise 1. 

3. Next time you go to the toilet to pass urine, try the ‘stop test’ about half way through 

emptying your bladder. Once you have stopped the flow of urine, relax again and 

allow the bladder to empty completely. You may only be able to slow down the 

stream. Don’t worry, your muscles will improve and strengthen with time and 

exercise. If the stream of urine speeds up when you try to do this exercise, you are 

squeezing the wrong muscles. 


Do not get into the habit of doing the ‘stop test’ every time you pass urine. This exercise should 

be done only once a day at the most. 

Now you know what it feels like to exercise the pelvic floor! 

Practising Your Exercises. 

1. Sit, stand or lie with your knees slightly apart. Slowly tighten and pull up the pelvic 

floor muscles as hard as you can. Hold tightened for at least 5 seconds if you can, then 

relax. Repeat at least 5 times (slow pull-ups). 

2. Now pull the muscles up quickly and tightly, then relax immediately. Repeat at least 5 

times (fast pull-ups). 

3. Do these two exercises – 5 slow and 5 fast – at least 4 times every day. 

4. As the muscles get stronger, you will find that you can hold for longer than 5 seconds, 

and that you can do more than 5 pull-ups each time without the muscle getting tired. 

5. It takes time for exercise to make muscles stronger. You are unlikely to notice 

improvement for several weeks – so stick at it! You will need to exercise regularly for 

several months before the muscles gain their full strength. 

Tips to Help You. 

1. Get into the habit of doing your exercise with things you do regularly – every time you 

wash your hands, every time you answer the phone…whatever you do often. 

2. Do the ‘stop test’ once a day when passing urine. Stopping your urine should get 

faster and easier. 

3. If you are unsure that you are exercising the right muscles, put one or two fingers in 

the vagina and try the exercises, to check. You should feel a gentle squeeze if you are 

exercising the pelvic floor. 

4. Use the pelvic floor when you are afraid you might leak – pull up the muscles before 

you squeeze or lift something heavy. Your control will gradually improve. 

5. Drink normally – at least 6-8 cups every day. And don’t get into the habit of going to 

the toilet ‘just in case’. Go only when you feel that the bladder is full. 

6. Watch your weight – extra weight puts extra strain on your pelvic floor muscles. 

7. Once you have regained control of your bladder, don’t forget your pelvic floor. 

Continue to do your pelvic floor exercises a few times each day to ensure that the 

problem does not come back. 

8. If you are doing physical exercises avoid high impact type as this weakens the pelvic 

floor muscle. We recommend yoga, Pilates, swimming, cycling and belly dancing as 

“good” exercises. 

You can do pelvic floor exercise wherever you are – nobody need know what you are doing! 

Pelvic Tilts. 

• Stand with your feet 12” apart approx 

• Slightly bend knees. 

• Rotate hips in a circle moving clockwise. 

• Continue hip rotation for 10 minutes twice a day. 

• Do not exercise if you have back/hip/knee pain/discomfort 

Do you have any Questions? 

This information sheet is designed to teach you how to control your bladder, so that you’ll be dry 

and comfortable. If you have problems doing the exercise, or if you don’t understand any part of 

this information sheet, ask your doctor, nurse, continence advisor or physiotherapist to help. 

Do your pelvic floor exercise every single day. Have faith in them. You should begin to see good 

results in a few weeks. 

For further information about coping with incontinence, contact:- 

Bladder and Bowel Foundation. Counsellor Helpline: 0870 770 3246 

www.bladderandbowelfoundation.org 

52 


1. Locate Bladder Muscle Group 



Pelvic floor Exercises for men 

• Contract or squeeze the same muscles used to stop the flow of urine 

• Pull up bladder muscles - hold tight for 5 seconds 

• Repeat this squeeze 5 times 

• Carry out this exercise 4 times a day 

2. Locate Rectal Muscle 

53 

Appendix 6a 

• Pretend you have wind. Pull up rectal muscles - hold tight for 5 seconds then relax slowly 

• Repeat squeeze 5 times 

Carry out this exercise 4 times a day 

3. Raise Entire Pelvic Floor 

• Find 4 opportunities in a day to tighten these muscles 4 times 

• Pull up - hold tight - breathe normally - relax slowly 

• Practice while sitting standing lying 

4. After-Dribble 

• To eliminate this problem ‘milk’ these last drops from the urethra with a finger before giving 

the shake 

Please remember to 

Exercise daily 


NOTES 

54 


How does this work? 



A BLADDER TRAINING GUIDE FOR PATIENTS 

WITH URINARY URGENCY AND FREQUENCY 

By “holding on” and delaying emptying your bladder, you will be able to enlarge its storage 

capacity and lengthen the time between needing to empty it. 

Concentrating on day time training will also have the benefit of helping with any night time 

problems. 

How long will it take to work? 

55 

Appendix 7 

It may take up to three months to establish a regular pattern but some sign of improvement should 

be noticed after a few weeks. 

How do I do the training? 

When you feel the need to empty your bladder, stand or sit still, contract the pelvic floor muscles 

and count for five seconds. 

If the urge to pass urine goes away, then there is no need to go to the toilet. If you still have the 

urge to pass urine contract the pelvic floor muscle again. 

Aim to delay going to the toilet for 5 minutes the first week, 10 minutes the second week if 

successful continue to increase delay by 5 minutes each week until you reach a satisfactory 

toileting pattern. 

Success depends on your willingness to do the exercises 


Appendix 7 contu... 

Bladder re-training contu…. 

Your nurse will guide you on how to do the pelvic floor muscle exercises and recording the 

information in a toilet diary. By completing a toilet diary, you will be able to see if the training is 

successful. 

Sometimes your nurse will ask your family doctor for some tablets that may help you to “hold 

on”. Follow the advice given regarding when to take them. 

How can I help the training programme? 

Follow the advice given to you by the nurse. 

Ensure you drink at least 10 mugs of fluid daily People over the age of 60 should drink 6-8 mugs 

of fluid daily. 

Try to reduce the amount of drinks that have a stimulating or irritating effect on the bladder i.e. 

coffee, tea, cocoa or orange, lemon, lime, pure juice, Cranberry juice. Note: reduce caffeine 

intake slowly i.e. cup a day less for a week, two cups the second week etc. 

Drink more fluids that do not irritate the bladder i.e. water, soups, meat extract drinks, 

blackcurrant squash, caffeine free tea and coffee. 

Avoid eating fresh tomatoes, red meat and dairy products. 

Stop drinking caffeine fluids after 6 pm but you can drink other types of fluids up till one hour 

before you go to sleep. 

To help you “hold on” and delaying emptying your bladder try to distract you’re self i.e. reciting a 

poem, reading a passage in book or by setting a specific time to aim for. 

Sitting on a hard seat or applying gentle pressure to the water outlet passage may help reduce the 

feeling of urgency you have. Your nurse can explain this in more detail for you. 

Points to remember 

You are trying to stretch the bladder and reduce its irritability. 

Nothing worth achieving is ever easy. It does take effort from you so follow the advice given you 

by your nurse. 

Your nurse is there to help you - so use them. 

The key to success is patience and perseverance. Don’t delay start today!! 

56 


INTERNATIONAL PROSTATE SYMPTOM SCORE 

NAME:________________________________________________________________________ 

DATE :________________________________________________________________________ 

Over the past month how often did the following happen? 

1. Incomplete 

emptying 

Had a sensation of not 

completely emptying 

your bladder? 

2. Frequency 

Urinate again less than 

two hours after you 

had finished? 

3.Intermittency 

Found you stopped and 

started again several 

times when you pass 

urine? 

4.Urgency 

Found it difficult to 

postpone urination? 

5.Weak Stream 

Had a weak urinary 

stream? 

6.Straining 

Had to push or strain 

to begin urination? 

7.Nocturia 

How many times were 

you woken up to pass 

urine at night? 

TOTAL SCORE 

Not at 

all 

0 

0 

0 

0 

0 

0 

None 

0 

Less 

than 

1 in 5 

times 

1 

1 

1 

1 

1 

1 

Once 

1 

Less 

than half 

the time 

2 

2 

2 

2 

2 

2 

Twice 

2 

57 

About 

half the 

time 

3 

3 

3 

3 

3 

3 

Three 

Quality of Life Score – please circle your response 

If you were to 

spend the rest 

of your life 

with your 

urinary 

condition just 

as it is now, 

how would 

you feel? 

Delighted 

0 

Pleased 

1 

Mostly 

satisfied 

2 

3 

Neither 

satisfied or 

dissatisfied 

3 

More 

than half 

the time 

4 

4 

4 

4 

4 

4 

Four 

4 

Mostly 

dissatisfied 

4 

Almost 

always 

5 

5 

5 

5 

5 

5 

Five or 

more 

5 

Unhappy 

5 

Appendix 8 

Score 

Score 

Terrible 

6 


I-PSS EXPLAINED 

58 

Appendix 8 contu… 

The International Prostate Symptom Score (I-PSS) is based on the answers to seven questions 

concerning urinary symptoms. Each question is assigned points from 0 to 5 indicating increasing 

severity of the particular symptom. The total score can therefore range from 0 to 35 

(Asymptomatic to symptomatic). 

Although there are presently no standard recommendations into grading patients with mild, 

moderate or severe symptoms, patients can be tentatively classified as follows :- 

0-7 = mildly symptomatic 

8-19 = moderately symptomatic 

20-35 = severely symptomatic. 

The International Consensus Committee (ICC) recommends the use of a single question to assess 

a patient’s quality of life. The answers to this question range from “delighted to terrible” or 0-6. 

Although this single starting question may or may not capture the global impact of Lower Urinary 

Tract Symptoms (L.U.T.S.) on quality of life, it may serve as a valuable starting point for a 

conversation between patient and their Doctor/Nurse. 




ENTITLEMENT OF CLIENTS TO RECEIVE INCONTINENCE PADS 

1. Management 

59 

Appendix 9 

Efforts should focus on identifying and treating the cause of the problem if this proves impossible 

then appropriate information should be given on obtaining aids/appliances or initiating a pad service 

if appropriate. 

2. Eligibility 

Clients must have an intractable chronic continence dysfunction. 

Clients requiring a pad of an absorbency of 200 mls or less are not eligible for free pads but should 

be given information on their purchase. This information is obtainable from the Continence 

Advisory Service, or local chemist shops. 

Clients must be registered with a GP whose practice is within NHS South Gloucestershire 

boundaries. 

Children with intractable incontinence are eligible to receive pads from the age of 4 years. 

Children with enuresis in accordance with nationally recognized treatment programmes, have no 

pads supplied. Over the age of 5 years, a referral to an Enuresis Clinic within the Trust should be 

initiated. 

Special schools do not receive incontinence pads direct. Pads are issued to clients who may leave 

pads at the school for use during school hours. 

Nursing Home clients are eligible to receive incontinence pads after assessment by the Funded 

Nursing Care Team based at Continence Advisory Service based at Kingswood Health Centre or 

Monarch Court. 

3. Supply of Incontinence Pads 

An incontinence assessment using the Care Pathway documentation must be undertaken by a 

competent Registered Nurse. 

Re-evaluations must be undertaken annually or the pad delivery service will be discontinued. 

Home Delivery Service documentation (HD Req) should be sent to the Continence Advisory 

Service for authorization. The Continence assessment record must be enclosed to support any 

order, this will be returned with a copy of the HD requisition form. 

Adults are to be issued with no more than 3 pads in 24 hours; children are to be issued no more that 

4 pads in 24 hours. Orders exceeding these levels should be discussed with the Continence 

Advisor. 


Policy contu… 

60 

Appendix 9 contu… 

Buffer stock is available in Health Centers/Clinics for patients requiring pads for less than one 

month i.e. Hospital Discharge pending Continence assessment. 

A full Continence assessment must be completed for patients if inco pads are still required after one 

month. 

Contact the Continence Advisory Service if your local Health Centre/Clinic runs out of buffer 

stock. 

Re usable pants and bed pads are not available. Information regarding purchase is obtainable from 

the Continence Advisory Service. 

4. Disposal of Incontinence Pads 

Contact local Council Environmental Health Office for up to date guidelines. 

5. Education 

Contact Staff Development Department regarding study days on Continence 

Promotion/Management of Incontinence. 

Contact Continence Advisory Service Kingswood Health Centre 0117 9677191 if new staff require 

induction. 

6. Contact Numbers 

Continence Advisor Kingswood Health Centre, 0117 9677191 or Fax 0117 9070046 for advice. 

Customer Services Paul Hartmann UK Ltd, Inco pad Home Delivery Service on 

0800 0289423 for advice/information on patients deliveries of pads or to put a stop on orders etc. 

Note early deliveries of pads/changes to pad orders must have approval of Continence Advisor. 

Date of Guideline April 2008 

Review date April 2010 


CONTINENCE IN A CONFUSED OLDER PERSON 

“Being demented: A Human Being imprisoned in a damaged brain” 

61 

Appendix 10 

The way we stay continent is a very complex function that allows us to voluntarily postpone passing 

urine, or having our bowels opened until we are at the appropriate place. 

This skill is something that can be affected by a cognitive impairment. It may happen occasionally 

or, as the illness progresses, more frequently. It is important to understand that it may be due to a 

treatable condition, so needs assessing. 

Lack of recall – when people become forgetful this may also mean they gradually lose the memory 

of what to do in a toilet, or even where the toilet is. This can be exacerbated by a move into new 

surroundings, or even a change in carer. 

How can you help? 

Get to know the person’s habits. This may be very personal, but usually our bladder and bowel 

actions have some pattern to them. It may be worthwhile noting when the person is most likely to 

use the toilet. As their memory deteriorates you can help them by reminding them to go to the toilet 

at times when you know they need the toilet. 

Make sure they drink 6-8 mugs of fluid during the day. People can forget to drink. 

Using the toilet is a very complicated thing to do, involving lots of different steps to be successful. 

Try to keep using the toilet to a few regular, easy steps. Always use the same language to ask or 

describe what is happening, and keep to the same routine inside the toilet. Occupational Therapists 

can be helpful in breaking down this task. 

Decide the toileting regime and tell others (Appendix 10a). 


Programme Other terms 

used 

Bladder training Bladder drill 

Bladder 

discipline 

Bladder reeducation 

Habit training 

Toileting schedule Timed voiding 

Prompted 

voiding 



TRAINING PROGRAMMES EXPLAINED 

62 

Appendix 10a 

Voiding 

intervals 

Occasions used Approach 

Increased Patients with Mandatory 

bladder instability schedule: must 

who are motivated only void at set 

and able to times even if they 

physically and become wet before 

mentally toilet that time is 

themselves reached. Increase 

interval when dry. 

Self-schedule: 

gradually increase 

interval at own 

discretion – may 

use toilet if 

desperate. 

Increased or Clients with Prompted toileting 

decreased cognitive schedule. May use 

impairment and/or toilet if voiding 

physical 

cannot be delayed. 

disabilities. Schedule can be 

Requires 

adjusted to fit 

motivated carers. client’s pattern, 

when there is no 

pattern prompt 

client to void 

every 2-3 hours. 

Take client to the 

toilet – do not rely 

on verbal prompts. 

Only clients with 

Spinal Injuries 

may include 

techniques to 

trigger voiding 

and allow 

complete 

emptying of 

bladder.

Continence Care Pathway - NHS South Gloucestershire

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