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women aged 26–82years and reported that 68% of women with fecal incontinence
reported also having urinary incontinence. Bliss and colleagues [4] showed that
51% of a sample of 189 community-dwelling men and women with fecal inconti-
nence also had urinary incontinence. This knowledge is useful for the advanced
practice nurse in assessing and managing the patient with fecal incontinence, as
bladder control should also be assessed.
13.2 Double Incontinence Relevance
According to the International Continence Society, double incontinence refers to
the involuntary loss of atus and/or feces in addition to urine [5]. This problem has
also been called dual incontinence and may refer to the loss of feces and urine with-
out atus. In studies examining the prevalence of double incontinence in commu-
nity-dwelling adult populations, estimated rates ranged from 3% to 8.8% [6–12].
Across studies, a variety of characteristics have been examined for their association
with double incontinence in community dwelling adults, mostly older adults.
Characteristics associated with increased odds of double incontinence in two or
more studies were older age [6, 7, 9–11], female sex (in studies including both men
and women) [6, 8, 12], depressive symptoms [8, 9, 11], presence or number of
comorbidities [6, 8], diabetes [7, 11], and functional impairment [6, 8, 9, 11]. In a
study examining the prevalence of double incontinence during pregnancy and post-
partum [13], the prevalence of double incontinence was 8.6% during pregnancy and
decreased to 3.5% postpartum in a large sample (n=1128) of nulliparous women
who were followed for an average of 7weeks postpartum.
Reports of the prevalence of double incontinence in non-community settings are
more limited. In a study of 9861 hospitalized patients, the prevalence of double
incontinence was 5.2%. While the overall prevalence was similar to that reported in
community-dwelling adults, the prevalence was much higher in patients in intensive
care units where it was 18.9% [14].
The prevalence of double incontinence in nursing home residents is much higher
than in the community. In one of the largest studies of nursing home residents, Bliss
and colleagues [15] reported a prevalence of 39.7% in a sample of 59,588 residents
in 555 nursing homes in the United States (US) while investigating dermatitis asso-
ciated with incontinence. Chiang and colleagues reported a prevalence of 54%
among 413 residents in 20 US nursing homes [16]. Saga and colleagues observed
that 40.2% of their sample of 930 residents from 27 nursing homes in Norway had
double incontinence [17]. Characteristics associated with double incontinence in
both studies were length of stay in the nursing home, cognitive impairment, and
functional impairment.
In one of the few reports on the incidence of double incontinence, Bliss and col-
leagues [18] examined data from 39,181 nursing home residents who were without
double incontinence on admission. The incidence of double incontinence at
6months after admission was 28%, and, at 1year, 42% of residents had double
incontinence. Predictors of the likelihood of developing double incontinence
J. P. Robinson and S. J. Engberg
277
included the presence of urinary incontinence on admission, older age, increased
comorbidities, greater functional impairment, and more severe cognitive impair-
ment [18].
While the prevalence of double incontinence varies across settings, it is relatively
common in adults and probably even more common in those with fecal inconti-
nence. The possibility of coexisting urinary incontinence needs to be considered
when evaluating patients with fecal incontinence and, if present, a treatment plan
for double incontinence should be developed.
13.3 Theoretical Perspective
The Theory of Unpleasant Symptoms [19] can be helpful in understanding the expe-
rience of double incontinence. This middle range theory posits that physiologic,
psychologic, and situational factors interact to inuence the symptom experience,
which is comprised of four separate but related dimensions: timing, intensity, qual-
ity, and distress. The symptom experience inuences performance of the individual.
Performance, in turn, can alter the symptom experience as well as physiologic, psy-
chologic, and situational factors through feedback effects. When two or more symp-
toms occur simultaneously, they interact to compound the impact on performance
(see Fig.13.1).
In the presence of double incontinence, the Theory of Unpleasant Symptoms
leads the advanced practice nurse to consider contributors to the symptoms
Fig. 13.1 The middle range theory of unpleasant symptoms [19]. (Reprinted with permission of
Wolters Kluwer Health, Inc.)
13 Management of Double Incontinence: Urinary Incontinence in the Presence…
278
experienced, including (a) physiologic factors such as pelvic oor muscle weak-
ness, medications, body mass index (BMI), fecal impaction, and deconditioning; (b)
psychologic factors such as anxiety, depression, and impaired cognition; and (c)
situational factors such as environmental barriers to continence and toileting, and
transitions from one care setting and/or caregiver(s) to another. Moreover, the the-
ory suggests that the timing, intensity, quality and distress of both fecal and urinary
components of double incontinence should be assessed in the context of all other
symptoms so that interventions can be prioritized and/or combined. The theory fur-
ther guides the advanced practice nurse to appreciate the impact of double inconti-
nence on performance of the individual in terms of physical activity, activities of
daily living, social activities and interactions, role enactment, concentration, think-
ing, and problem-solving. Finally, the theory prompts the advanced practice nurse
to understand an individual’s performance as a function of the synergistic and com-
bined impact of all symptoms and, in turn, as a contributor to the expression of each
symptom and to physiologic, psychologic, and situational factors that inuence
symptom expression.
13.4 Urinary Incontinence Types
Urinary incontinence is a component of double incontinence and refers to “the com-
plaint of any involuntary loss of urine” [20]. Essentially, urinary incontinence is a
problem with bladder storage; as such, it is classied according to patient descrip-
tions about when involuntary urine loss occurs. The most common types of urinary
incontinence are stress urinary incontinence, involuntary urine loss with effort or
exertion or when sneezing or coughing; urge urinary incontinence, involuntary
urine loss accompanied or immediately preceded by urgency; and mixed urinary
incontinence, involuntary urine loss associated with urgency and also during effort,
exertion, coughing, or sneezing. Table13.1 presents the denitions of urinary incon-
tinence by type and subtype according to the seventh International Consultation on
Incontinence published by the International Continence Society and International
Consultation on Urologic Diseases [20].
While there is wide variation in the reported prevalence of urinary incontinence
in community-dwelling women, in most studies, it is between 25% and 45%; stress
urinary incontinence is the most common subtype of urinary incontinence, followed
by mixed incontinence and isolated urge urinary incontinence. Studies examining
age-related differences in the prevalence of urinary incontinence consistently report
that the prevalence increases with age, and most studies report that mixed urinary
incontinence becomes the predominate subtype. Body mass index (BMI) and mode
J. P. Robinson and S. J. Engberg
279
Table 13.1 Classication of urinary incontinence
a
Type or subtype of
urinary incontinence Denition
Urgency Complaint of involuntary urine loss associated with urgency
Stress Complaint of involuntary urine loss with effort or physical exertion or
upon sneezing or coughing
Mixed Complaint of involuntary urine loss with urgency and also with effort or
physical exertion or upon coughing or sneezing
Postural Complaint of involuntary urine loss occurring with changes in body
position such as rising from a seated or lying position
Incontinence
associated with
chronic retention
of urine
Complaint of involuntary loss of urine that occurs in conditions where the
bladder does not empty completely as indicated by a signicantly high
residual urine volume and/or a non-painful bladder which remains
palpable after the individual has passed urine (note: The term overow
incontinence is no longer recommended. A signicant residual urine
volume denotes a minimum volume of 300ml, although this gure has
not been well established.)
Nocturnal enuresis Complaint of involuntary urine loss during sleep
Continuous Complaint of continuous involuntary urine loss
Insensible Complaint of involuntary urine loss without the individual being aware of
how it occurred
Coital (women
only)
Complaint of involuntary urine loss during coitus, occurring with
penetration, at orgasm, or during both
Functional Complaint of involuntary urine loss from inability to reach the toilet due
to cognitive, functional, or mobility impairment in the presence of an
intact lower urinary tract system
Multifactorial Complaint of involuntary urine loss related to multiple interacting risk
factors, including factors within and outside the lower urinary tract such
as comorbidities, medications, age-related physiologic changes, and
environmental factors
a
According to the seventh International Consultation on Incontinence published by the International
Continence Society and International Consultation on Urologic Diseases [20]
of delivery (vaginal) are the two risk factors other than aging that have the most
research supporting their association with urinary incontinence in women [21].
Less is known about the rate of urinary incontinence in men than in women, but
the prevalence appears to be much lower (urinary incontinence is probably at least
twice as common in women than men). Similarly, regarding double incontinence in
men, Bliss and colleagues [22] surveyed 1352 community-dwelling older adults and
found that 55% of women versus 28% of men had double incontinence [22]. As
with fecal incontinence, there is a steady increase in the prevalence of urinary
incontinence as men age [23]. The most common type of urinary incontinence in
men is urge urinary incontinence, followed by mixed urinary incontinence and
stress urinary incontinence.
13 Management of Double Incontinence: Urinary Incontinence in the Presence…
280
13.5 Risk Factors forUrinary Incontinence
In addition to increasing age, other lower urinary tract symptoms, urinary tract
infections, cognitive and functional impairment, diabetes, alcohol intake, neuro-
logic disorders, and prostatectomy have been shown to increase the risk for urinary
incontinence in men [21]. Some of the risk factors for urinary incontinence in men
and/or women are also risk factors for fecal incontinence although research support-
ing this is not as strong as it is for urinary incontinence. The risk factor with the
most support for both urinary incontinence and fecal incontinence is aging. Diabetes
and neurological diseases such as Parkinson’s disease and stroke have also been
associated with an increased risk for both urinary incontinence and fecal inconti-
nence as have cognitive and ADL impairments. While studies show a consistent
association between obesity and urinary incontinence, those examining the associa-
tion with fecal incontinence are inconsistent [21].
13.6 Assessment ofUrinary Incontinence
Given that many patients with fecal incontinence are likely to have double inconti-
nence, it is important for the advanced practice nurse to include questions about
bladder function when assessing patients with fecal incontinence. Many patients
with urinary incontinence do not report this problem to a healthcare provider unless
directly asked about bladder function. Questions that may be helpful in eliciting the
presence of urinary incontinence include asking about problems with bladder con-
trol, involuntary urine loss, and the use of pads and why they are being used. In
patients experiencing urinary incontinence, a careful history should be the rst step
in assessing the problem (see Table 13.2). Guided by the Theory of Unpleasant
Symptoms, questions should be asked to determine the factors that precipitate invol-
untary urine loss as well as the frequency and amount (indicators of severity) of
leakage; day- and night-time voiding frequency, as well as nocturia; uid intake
(amount and type); measures used to contain leakage; impact of urinary inconti-
nence on quality of life; previous treatment for urinary incontinence and its effects;
as well as comorbid conditions, current medications, functional impairments, the
desire and goals for treatment, and treatment expectations.
The advanced practice nurse should perform a focused physical examination
when evaluating urinary incontinence, which includes an abdominal exam, neuro-
logic exam, a pelvic exam in women, and a rectal exam in men. A bladder diary is
very useful in establishing the type, frequency, and severity of urinary incontinence,
as well as voiding frequency, volume, and uid intake. If feasible, patients should
complete a 2- to 3-day diary. In addition to its usefulness in the diagnostic process,
the bladder diary is very helpful in monitoring the effectiveness of treatment [20]
(see Table13.3).
J. P. Robinson and S. J. Engberg
281
Table 13.2 History-taking for urinary incontinence
Continence history
Duration Length of time and progression of symptoms
Frequency How often involuntary urine loss occurs; self-reported number of
incontinent episodes per day, week, or month
Severity How much typically leaks with urinary incontinence episodes—a few drops,
enough to make clothing or pad damp, or soaks pad or clothing
Precipitating
factors
When does involuntary urine loss occur—Coughing, sneezing, laughing,
lifting, exercise, urgency, sight or thought of the toilet, “key in the door,”
running water, changing position, during sexual activity, continuous leaking,
leaking without awareness of precipitating factor identiable, involuntary
urine loss while sleeping (enuresis)
Voiding
frequency
How often voids typically occur during the day
How many times a patient gets up from sleep to void (nocturia), does
urgency wake up patient, impact of loss of sleep
Fluid intake Fluid intake during the day and the evening
Type of uid intake; ask specically about caffeinated uids and alcohol
intake and amount
Urine
containment
measures
Measures used to contain involuntary urine loss—Specic products used
(with frequency changed/used)
Associated
symptoms
Pain or burning on urination (dysuria), blood in urine (hematuria), lower
abdominal pain, difculty emptying bladder, pelvic organ prolapse
symptoms
Previous
treatment
Past/current treatments for urinary incontinence and their effectiveness
Impact on
quality of life
Inuence on well-being (e.g., physical, psychosocial, functional, economic)
General medical history
Functional
limitations
Mobility and cognition decits
Comorbidities Diabetes, heart failure, neurologic disorders
Medications Medications currently taken
Past medical history
Obstetric history
(women)
Number of pregnancies, type of delivery, complications
Previous
surgery/
radiation
Abdominal, pelvic, prostate (men)
Treatment expectations
Desire for
treatment
Willingness to be treated, and preferred and acceptable treatment options
Treatment
expectations
Goals related to reducing urinary incontinence and other lower urinary tract
symptoms
13 Management of Double Incontinence: Urinary Incontinence in the Presence…
282
Table 13.3 Focused physical examination for urinary incontinence
Physical examination
Abdominal exam Suprapubic dullness, tenderness, or palpable bladder
Neurologic exam
Pelvic exam in women Pelvic oor muscle tone and strength
Pelvic organ prolapse
Rectal exam in men Prostate enlargement or nodules
Bladder diary (2–3days)
Additional tests as indicated, e.g., post-void residual urine, urinalysis, urodynamic testing
13.7 Interventions forUrinary Incontinence
While some interventions may have benecial effects on both fecal incontinence
and urinary incontinence, the advanced practice continence nurse needs to consider
the patient’s and, if relevant, caregivers’ preferences when developing an interven-
tion plan for double incontinence. Which symptoms are most bothersome to the
patient? What do they want to focus on during the initial treatment? Which treat-
ments are acceptable? What are their outcome expectations relative to treatment? In
a systematic review, Riemsma et al. [24] examined cure rates following various
treatments for urinary incontinence and fecal incontinence. “Cure was dened as no
leakage (urinary incontinence) and/or no episodes of fecal incontinence at trial-
specied time points of at least 3 months” [24] (p.2). Based on their ndings that
cure rates were relatively low for most interventions examined for both urinary
incontinence and fecal incontinence, improvement is a more realistic goal than cure
for many patients with both types of incontinence.
There are many treatment options for urinary incontinence with the choice of
interventions based on the type and severity of urinary incontinence as well as
patient preferences. This chapter will focus on conservative management of urinary
incontinence, interventions not involving surgical or pharmacological approaches
[2], and some management approaches that are similar to those for fecal inconti-
nence addressed in other chapters of this book. These interventions are summarized
in Table13.4. They include lifestyle modications, behavioral therapies, toileting
programs, electrical stimulation, and posterior tibial nerve stimulation. Conservative
interventions are generally recommended as the initial treatment approach for uri-
nary incontinence and for those for whom other treatments are inappropriate.
13.7.1 Lifestyle Interventions forUrinary Incontinence
Lifestyle interventions, such as weight loss, dietary and uid modications, smok-
ing cessation, and the avoidance of constipation, are low-cost and non-invasive
options for treating urinary incontinence. While these interventions are often rec-
ommended as part of the treatment program for urinary incontinence, many lack
rigorous research to draw conclusions about their effectiveness and treatment relies
J. P. Robinson and S. J. Engberg
283
Table 13.4 Conservative treatment options for urinary incontinence
Intervention
Strength of evidence for
urinary incontinence
Strength of evidence for fecal
incontinence
Lifestyle modications
Weight reduction Strong evidence for overweight
and obese women; some
evidence for men
Inconsistent
Physical activity to
reduce abdominal fat
Limited evidence to support in
overweight women with urge
urinary incontinence
Study limitations result in inability
to assess a causal relationship
Fluid intake Some evidence to support
adequate uid intake; some
evidence to support minor
reductions as long as intake is
not <30mL/kg/day
Has not been examined
Reduce caffeine
intake
Some evidence to support Limited evidence does not support
Vitamin D supplement Some evidence to support in
post-menopausal black women
Has not been examined
High fruit, vegetable
and whole grain diet
Limited evidence to support a
small effect independent of
weight loss
Some evidence to support increasing
ber intake to near recommended
dietary levels
Smoking cessation Limited evidence to support in
women and men
No evidence
Behavioral therapies
Pelvic oor muscle
training (PFMT)
Strong evidence to support in
individuals able and willing to
actively participate
Some evidence supports as part of a
conservative management bundle;
strong evidence supports
biofeedback, usually combined with
PFMT and sensory training with a
rectal balloon as a second line
intervention
Bladder training Strong evidence to support
effectiveness in women able
and willing to actively
participate
Not applicable
Toileting programs
(for individuals
unable to actively
participate in
self-management
activities)
Strong evidence of short-term
benet of prompted voiding
when caregivers adhere to
treatment protocol; limited
research examining scheduled
toileting and habit training
Limited evidence
(continued)
13 Management of Double Incontinence: Urinary Incontinence in the Presence…
284
Table 13.4 (continued)
Intervention
Strength of evidence for
urinary incontinence
Strength of evidence for fecal
incontinence
Electrical stimulation Some evidence to support in
women
Limited evidence; low-frequency
electrical stimulation does not
appear to be helpful; medium
frequency may be benecial in
combination with biofeedback, but
additional research is needed to
conrm
Posterior tibial nerve
stimulation
Limited evidence to suggest
may be effective for urge
urinary incontinence;
Some evidence to support use
in combination with other
interventions in women with
urge urinary incontinence
Some evidence supports not using in
clinical practice
on clinical experience. The lifestyle intervention that has sufcient current research
evidence to support its effectiveness in reducing urinary incontinence is weight loss
in overweight and obese women. The seventh International Consultation on
Incontinence gave recommending weight loss in overweight and obese women a
grade A recommendation based on level 1 evidence (evidence from the meta-
analysis of randomized controlled trials (RCTs) or well-designed RCTs). There is
also some evidence to support recommending weight loss for overweight or obese
men with urinary incontinence, but it is much more limited than research examining
this intervention in women. In the presence of double incontinence, in addition to
improving urinary incontinence in overweight or obese women and men, it is pos-
sible that weight loss may also improve the coexisting fecal incontinence; however,
evidence supporting this benecial effect is inconsistent [2]. Although not as strong
as the evidence related to weight loss, there is some evidence to support that reduc-
ing caffeine intake may reduce urinary incontinence. There is also some evidence to
support recommending minor reductions in uid intake (by 25%) as long as base-
line uid intake is not less than 30mL/kg per day [2]. The effects of restricting
caffeine intake and reducing uid intake have not been examined in relation to fecal
incontinence and limitations in the only study examining uid intake make it impos-
sible to determine a causal relationship between uid intake and fecal inconti-
nence [25].
While there are many good health reasons to recommend that patients stop smok-
ing, there is limited research examining the impact of smoking cessation on urinary
incontinence and none in fecal incontinence [25]. Constipation has been associated
with fecal incontinence, and there is limited evidence from small observational
studies to suggest that it may be a risk factor for urinary incontinence. Some notions
are that a bowel lled with feces presses on the bladder reducing its capacity or
creating a sense of urgency and straining during constipation weakens pelvic oor
muscles. While clinicians often recommend measures to treat or prevent
J. P. Robinson and S. J. Engberg
285
constipation in individuals with urinary incontinence, there is limited research
examining the effect of this recommendation [2]. One of the rst-line nonconserva-
tive treatments for urge urinary incontinence and overactive bladder is antimusca-
rinic drugs. One of the bothersome side effects of these medications is constipation.
When treating patients with double incontinence, clinicians need to carefully review
the medications that patients are taking and weigh their risk-benet ratio in relation
to both urinary incontinence and fecal incontinence.
13.7.2 Behavioral Therapies forUrinary Incontinence
Behavioral therapies, pelvic oor muscle training, bladder (re)training, and toileting
programs are widely recommended conservative approaches to managing urinary
incontinence that the advanced practice continence nurse can perform. The pelvic
oor muscles provide structural support for the pelvic organs including the bladder
and lower bowel and their openings. Improving the strength of these muscles is
hypothesized to improve this support. Pelvic oor muscle training includes assess-
ing the ability to contract these muscles, education about how to perform pelvic
oor muscle exercises, and instructions on the active use of the muscles to prevent
involuntary urine loss. Across research studies, pelvic oor muscle training pro-
grams vary in terms of clinician supervision, the intensity of the training, instruc-
tional method, type of training, and inclusion of other treatment modalities. Based
on a recent review of these studies, there is strong evidence supporting pelvic oor
muscle training with regular clinician supervision as the rst-line conservative ther-
apy for women of all ages with urinary incontinence [2], There is some evidence
that early pelvic oor muscle training (in the pre-operative or early post-operative
period) can reduce the time to return to continence following radical prostatectomy
[2]. There is no clear benet from using biofeedback to teach pelvic oor muscle
exercises, and while research is more limited, adding other modalities to the pelvic
oor muscle training regimen does not appear to enhance its benecial effects [2].
Once patients learn to contract and relax their pelvic oor muscles, if they have
stress urinary incontinence, they should be taught to contract their muscles during
activities that produce involuntary urine loss such as coughing and sneezing. If they
have urge urinary incontinence, they can be taught to contract their pelvic oor
muscles to suppress urgency and then walk to the toilet at a normal pace, which
decreases the likelihood of involuntary urine loss. Pelvic oor muscle training tech-
niques for urinary incontinence and fecal incontinence are similar and may reduce
fecal incontinence as well as urinary incontinence although there is less research
evidence to support efcacy for fecal incontinence than there is for urinary inconti-
nence [2, 25]. However, pelvic oor muscle training is part of the initial manage-
ment of fecal incontinence [25]. Pelvic oor muscle training for fecal incontinence
also focuses on strengthening contraction of the external anal sphincter, which is
under voluntary control and increasing sensory awareness of the need to defecate
as needed.
13 Management of Double Incontinence: Urinary Incontinence in the Presence…