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286
In contrast, while evidence does not support the use of biofeedback-augmented
pelvic oor muscle training for urinary incontinence, the seventh International
Consultation on Incontinence found that biofeedback-augmented pelvic oor mus-
cle training may be more effective than pelvic oor muscle training alone in fecal
incontinence. Biofeedback, usually in combination with pelvic oor muscle train-
ing and sensory training with a rectal balloon, is recommended as a second-line
therapy for fecal incontinence when pelvic oor muscle training alone and other
conservative therapies have not provided adequate symptom relief [25].
Bladder training, also called bladder retraining, can be another effective inter-
vention for urinary incontinence, particularly urge urinary incontinence and mixed
urinary incontinence with concurrent urgency and urinary frequency (i.e., overac-
tive bladder). The goal of this intervention is to improve bladder capacity and reduce
urinary frequency. The patient is instructed to void at xed intervals (“by the clock”)
based on their average baseline voiding interval. Alternately, some clinicians have
the patient begin by voiding every hour. The voiding interval is gradually increased
by 15–30min with the goal of achieving a more normal voiding interval, usually
every 3–4h. Individuals are instructed to void at the scheduled times even if there is
no urge to urinate; if urgency occurs prior to the scheduled voiding time, they are
instructed to try to suppress the urgency using distraction techniques or by contract-
ing their pelvic oor muscles. There is strong evidence from randomized clinical
trials to recommend bladder training as a rst line conservative treatment for urinary
incontinence in women [2]. Evidence also suggests that bladder training may be
effective in additional populations when there is direct clinician supervision [2].
Although there is considerably less evidence supporting bowel training for defeca-
tion urgency, a consensus of the International Continence Society describes how
similar techniques used in bladder training can be applied for bowel training [26].
13.7.3 Neuromodulation forUrinary Incontinence
Electrical stimulation, generally a clinic-based intervention, increases propriocep-
tion and/or muscle strength when used to treat stress urinary incontinence, while the
goal when used to treat urge urinary incontinence is often to inhibit detrusor over-
activity. Based on studies comparing electrical stimulation to no active treatment,
electrical stimulation might be better than no treatment for stress urinary inconti-
nence and urge urinary incontinence (grade B recommendation, consistent evidence
from low-quality randomized clinical trials, meta-analysis of good quality cohort
studies, good quality retrospective case-control or case series studies) [2]. There is
a need for more well-designed clinical trials to establish whether or not electrical
stimulation is effective in treating urinary incontinence. There is very limited
research examining the effectiveness of electrical stimulation for fecal incontinence,
but low level (100 Hz) electrical stimulation does not appear to be helpful [2].
Medium-frequency may be benecial in combination with biofeedback, but addi-
tional research is needed to conrm this [25].
J. P. Robinson and S. J. Engberg
287
Posterior tibial nerve stimulation is a form of neuromodulation that provides
indirect access to the sacral plexus through intermittent, electrical stimulation of the
posterior tibial nerve through insertion of ne needles close to the nerve, or through
surface electrodes applied to the area of the medial malleolus. Treatments are usu-
ally administered weekly for a period of 2–3months. Studies examining posterior
tibial nerve stimulation have small sample sizes and were assessed by the seventh
International Consultation on Incontinence as having a high risk of bias [2]. Based
on this, they concluded that posterior tibial nerve stimulation may be more effective
than no treatment for symptom control in women with urge urinary incontinence
and overactive bladder and that transcutaneous (surface) and percutaneous tibial
nerve stimulation are equally effective [2]. Due to a lack of evidence supporting the
use of posterior tibial nerve stimulation for fecal incontinence, it cannot be recom-
mended for clinical practice [25].
Most urinary incontinence intervention research studies have been conducted in
community-dwelling women. There is much less research in men and what has been
done has primarily focused on post-prostatectomy urinary incontinence. According
to the seventh International Consultation on Incontinence, treatment recommenda-
tions for men with urinary incontinence include weight loss for those who are obese
or overweight, particularly those with Type 2 diabetes, smoking cessation for those
who smoke, and reducing caffeine intake [2]. The sixth International Consultation
on Incontinence recommended pelvic oor muscle training for men with urinary
incontinence [27]. The recommendations related to pelvic oor muscle training in
the seventh International Consultation on Incontinence focused on studies examin-
ing it in men who had radical prostatectomies. They concluded that it can be recom-
mended either in the pre-operative or early post-operative period to reduce the time
to restoring continence [2]. Adding electrical stimulation to pelvic oor muscle
training does not appear to improve outcomes. Posterior tibial nerve stimulation is
a potential treatment option for men with urge urinary incontinence and overactive
bladder who do not achieve satisfactory outcomes with lifestyle and behavioral
interventions and pharmacotherapy. For all of these recommendations, evidence is
limited [2].
13.8 Managing Urinary Incontinence intheFrail Older Adult
Frail older adults constitute a group where the prevalence of both urinary inconti-
nence and double incontinence are higher than among healthy adults. Many frail
older individuals have coexisting disabilities and comorbidities. These can both
contribute to urinary incontinence and to response to urinary incontinence-specic
interventions. Management of urinary incontinence in this population needs to start
by identifying and treating comorbid conditions and impairments that may be con-
tributing to the incontinence [28]. While there is no research examining the effects
of lifestyle interventions in treating urinary incontinence in this population, these
interventions may be appropriate in select frail older adults with some caveats [29].
13 Management of Double Incontinence: Urinary Incontinence in the Presence…
288
For example, weight loss may be inappropriate, and caution should be exercised in
recommending uid restriction as many frail elders are at risk for inadequate uid
intake and dehydration, particularly long-term care residents.
Because of their minor side effects, behavioral interventions are generally con-
sidered a rst-line treatment for urinary incontinence in this population. Toileting
programs are recommended for frail older adults with cognitive or physical impair-
ments that limit their ability to actively participate in self-care activities, but may be
used in other frail elders as well. Toileting programs for urinary incontinence
include prompted voiding, scheduled toileting, and habit training (see Box 13.1).
Toileting interventions for urinary incontinence all depend on active caregiver
involvement. The intervention that has been examined most often in research stud-
ies is prompted voiding. Research on habit training and scheduled toileting is very
limited. Based on current evidence, it is uncertain if these interventions reduce
urinary incontinence in frail older individuals. There is good evidence, primarily
from studies conducted in long-term care settings, that prompted voiding is effec-
tive as a short-term treatment for daytime incontinence when caregivers adhere to
the treatment protocol [29]. There is a lack of research examining the long-term
effect of this intervention. Given that prompted voiding increases caregiver burden,
it is important to target it to those most likely to benet. It is not recommended for
individuals who need the assistance of more than one person during toileting, those
who cannot follow one-step commands, and those who have less than a 20% reduc-
tion in wet checks or toilet appropriately less than 66% of the time during a 3-day
trial of the intervention [29]. There is also good evidence to support combining
toileting and functional training when treating urinary incontinence in nursing
home residents. There is limited research examining the effect of toileting inter-
ventions on concurrent fecal incontinence. Multicomponent interventions in nurs-
ing home settings that included a toileting program did not reduce fecal
incontinence, although bowel frequency and the number of continent bowel move-
ments improved [29].
Box 13.1 Toileting Programs for Urinary Incontinence
• Prompted voiding, which combines regular prompts to void with positive
feedback for appropriate toileting. The goals are to increase awareness of
the need to urinate and self-initiated toileting.
• Scheduled toileting, which is regular toileting without prompts or rein-
forcement for appropriate voiding.
• Habit training, which matches the toileting schedule to the individual’s
voiding pattern established during a baseline assessment (bladder diary/
wet checks) to determine the frequency of continent and incontinent voids.
The goal is to preempt incontinent episodes.
J. P. Robinson and S. J. Engberg
289
For frail individuals who are cognitively intact and able to actively participate in
bladder-related self-care, bladder training and pelvic oor muscle training may be
effective treatment options. There is, however, limited research examining these
interventions in this population. Tally etal. [30] conducted a systematic review of
conservative treatments for urinary incontinence in frail community-dwelling older
adults. They identied three studies, with only one randomized controlled clinical
trial, that examined multicomponent behavioral interventions that included pelvic
oor muscle training and bladder training. All three studies reported signicant
reductions in urinary incontinence episodes at the end of the interventions (75–80%
reductions). Engberg and Sereika [31] compared the effectiveness of biofeedback-
taught pelvic oor muscle training in reducing urinary incontinence in frail (home-
bound) and non-frail community-dwelling older adults and reported that there was
no signicant difference in the median percent reduction in urinary incontinence
episodes in the two groups (64.5% in the frail and 70.4% in the non-frail subjects).
13.9 Environmental Factors
Environmental factors, specically lack of easy access to the toilet and timely toilet-
ing assistance, are risk factors for urinary incontinence particularly in caregiver-
dependent individuals. Improving access to the toilet (e.g., use of bedside commodes,
especially if the only toilet is on the second level of a house) and providing toileting
aids such as grab bars and raised toilet seats may improve continence (both urinary
and fecal) in individuals with mobility and functional impairments. Increasing toilet
visibility or adding signage or images to show where the toilet is may be effective
in increasing appropriate toileting in individuals with cognitive and visual- perceptual
impairments [29]. In caregiver-dependent individuals, the need for timely toileting
assistance is a critical but often neglected risk factor for urinary incontinence. For
individuals who cannot toilet independently, the availability of timely toileting
assistance is critical to the success of all other interventions for both urinary incon-
tinence and fecal incontinence.
13.10 Products forContaining or Collecting Incontinent Urine
As previously noted, complete cure of double incontinence may not be a realistic
goal for many individuals, and even when effective, interventions often take time to
work. Consequently, continence products that contain or collect leaked urine have a
role in incontinence management for many adults. They should not, however, be a
substitute for active assessment and treatment of urinary incontinence or double
incontinence. Available products vary by country and include toileting products
(commodes, bedpans, handheld urinals), absorbent products, external urine collec-
tion devices, mechanical devices, and catheters (intermittent and indwelling). The
choice of products will vary with availability, the severity and type of incontinence,
13 Management of Double Incontinence: Urinary Incontinence in the Presence…
290
functional ability, and personal preferences (patient and caregiver). A combination
of products is often the best option for managing incontinence [32]. There is an
interactive web site available to provide current product-related evidence to help
users and healthcare providers in the selection of products and how to best use
them [33].
Body-worn absorbent pads are the most commonly used products to manage
urinary incontinence. Clinicians need to remember that pad use is not without risks
including increased risk for new onset and worsening incontinence, urinary tract
infections, and incontinence-associated dermatitis (see Chap. 15). There is a wide
variety of absorbent products available, and the best product for any given individ-
ual varies with a variety of characteristics including the frequency and severity of
incontinence, whether it occurs during the day or night, sex (men or women), pad
changing position, personal priorities and preferences, lifestyle, and caregiver needs
and preferences [32]. While there are pads made specically for fecal incontinence,
the individual with double incontinence will often elect to wear a pad that is also
effective in containing urine leakage [4].
13.11 Summary
Many patients with fecal incontinence will also have urinary incontinence. Thus, it
is important for the advanced practice nurse to ask patients with fecal incontinence
about coexisting urinary incontinence. If urinary incontinence is also present, it
needs to be considered when planning and initiating a plan of management/treat-
ment for fecal incontinence. The Theory of Unpleasant Symptoms can help the
advanced practice nurse to understand the experience of double incontinence from
the patient’s perspective. While there are unique interventions for the urinary and
fecal components of double incontinence, there are some interventions that may be
effective for both. Box 13.2 presents a case study of management of double incon-
tince by an advanced practice nurse.
Box 13.2 Case Study
Management of Double Incontinence: Urinary Incontinence in the Presence
of Fecal Incontinence
Bebe Fadden, a retired college professor, suffers from double incontinence.
Bebe, as she prefers to be addressed, is 86years old and moved to an assisted
living facility 6weeks ago. Her husband died 2years ago and she has no fam-
ily in the area. Her only child, a daughter, lives 300miles away but calls sev-
eral times a week and visits several times a year. Prior to her transition to
assisted living, Bebe enjoyed visits with friends in her neighborhood for card
games and lunch several times a month.
(continued)
J. P. Robinson and S. J. Engberg
291
Box 13.2 (continued)
Past health history:
• Hypertension.
• Osteoporosis.
• Arthritis.
• Fractured hip with surgical repair 3years ago.
• Falls x3 without serious injury over past 6months.
• Celiac disease X 20years managed with gluten-free diet.
Current medications: Antihypertensive, diuretic, antacids prn, analgesic
prn, psyllium.
Function: Mostly independent in activities of daily living (ADLs) and rel-
evant instrumental activities of daily living (IADLs) (e.g., medication intake,
simple meal preparation, light housekeeping, personal nances). Sleeps 6 to
7h/night and naps 2 to 3 times/day but still feels “tired all the time.” Cognition
intact. Narrow-base quad cane used since hip surgery for long distances and
outdoor mobility; however, cane used more over the past several weeks due to
occasional dizziness.
History of Presenting Problem:
• Bowel: Constipation X 1 month with fecal incontinence that developed
during past 2weeks; leakage occasional @ rst, now small amounts 2 to 3
times/day, but has had constant stool seepage a few times.
• Bladder: Urgency and frequency × 2weeks with increasing episodes of
leakage in small amounts every day.
• Self-care: Started wearing absorbent brief last week; “I am too nervous and
embarrassed to go anywhere or do anything;” “I can’t keep myself clean;”
“I watched what I ate for 20 years and never had a problem; now my blad-
der doesn’t even work the right way.” Appetite diminished: “I’m not really
hungry; I feel bloated most of the time.”
Physical Findings:
• Vital signs within usual range; negative for orthostatic hypotension;
afebrile.
• Body Mass Index 28 (within normal limits for age).
• Gait steady, but turns slowly and counter-surfs indoors.
• Abdomen rm, non-tender; no supra-pubic tenderness.
• Moderate amount of hard formed stool palpated on digital rectal exam.
• Urine dark amber with strong odor; no dysuria.
• Perineal and perianal skin intact and without irritation.
• Dry, sticky mouth.
(continued)
13 Management of Double Incontinence: Urinary Incontinence in the Presence…
292
Box 13.2 (continued)
Analysis:
The Theory of Unpleasant Symptoms offers a framework for organizing
and analyzing Bebe’s symptom experience (see Table 13.5); physical, psy-
chologic and situational factors that inuence symptom expression (see
Table13.6); and performance relative to mobility, activities of daily living,
social engagement, role execution, and cognitive skills (see Table13.7).
Table 13.5 Symptom experience
Symptom
Timing Intensity Quality
Distress
Bowel:
Constipation
& fecal
incontinence
Constipation
× 1month;
“leaky” stool
× 2weeks,
occasional at
rst, now
small
amounts 2 to
3×/day;
constant
seepage a
few times
1 to 2 formed
stools/week; light
soiling from stool
leakage
Formed stools
hard; liquid
stool leakage;
constant
bloated feeling
High: Wears
absorbent brief
daily with 1 to 2
changes/day; “too
nervous &
embarrassed to go
anywhere or do
anything.”
Bladder:
Urgency,
frequency, &
urinary
incontinence
Urgency &
frequency ×
2weeks;
urine
leakage
daily or
more
1 to 2 voids/hour,
small amounts,
associated w/
mild to moderate
urge; small
amounts of urine
leakage daily or
more, usually on
the way to the
bathroom
Dark, cloudy
amber urine w/
strong odor; no
pain w/
voiding
High: Urinary
incontinence is a
new symptom;
“now my bladder
doesn’t even work
the right way.”
Dizziness Occasional
dizziness X
2weeks,
mostly when
rising from
chair or bed
or turning
around
Mild: Disappears
w/ “staying still
for a minute or
so”
Predictable
when rising; it
“catches me by
surprise
sometimes
when I’m
walking &
turning”
Moderate: “I use
my cane more
now and it gives
me something to
hold on to if I feel
dizzy.”
Loss of
appetite
Gradual X
past month;
stopped
going to
congregate
meals
3weeks ago
Eats “what I can
off my tray;” does
not eat or drink
between meals
“Not really
hungry;” feels
“bloated most
of the time”
Mild to moderate:
“I don’t like the
food here and I
can’t get things
that I like and can
eat.”
(continued)
J. P. Robinson and S. J. Engberg
293
Box 13.2 (continued)
Table 13.6 Inuencing factors
Physiologic
Psychologic
Situational
86years old Anxiety: “I am too nervous
and embarrassed to go
anywhere or do anything”
Recent move to assisted
living facility
Medical diagnoses:
Hypertension.
Osteoporosis.
Arthritis.
Celiac disease (×
20years)—Gluten-free
diet.
Sadness/loss:
“I can’t keep myself
clean.”
“I watched what I ate
for 20years and never
had a problem; now I
can’t even pee the right
way.”
Recent transition to
assisted living facility
Husband deceased 2years
ago
Surgery:
Fractured hip 3years
ago.
Retired college professor
Medications:
Antihypertensive.
Diuretic.
Psyllium.
Antacids prn.
Analgesic prn.
No family in area: Regular
phone contact with
daughter, who lives
300miles away (visits “a
few times/year”)
Risks:
3 falls without serious
injury over past
6months.
Prior to assisted living
facility admission, enjoyed
visits with neighborhood
friends for lunch and card
games several times/months
Table 13.7
Performance
Mobility Gait steady but turns slowly and counter-surfs indoors.
Narrow-base quad cane used since hip surgery for long distances
and outdoor mobility; however, using cane more x past several
weeks due to occasional dizziness
Activities of daily
living (ADLs)
Struggling with bowel and bladder continence; otherwise
independent
Social engagement Self-isolating due to fecal and urinary incontinence
Sadness/loss related to incontinence
Anxiety related to potential for public incontinence
Relatively recent widow
Connected to daughter via regular phone calls but visits
infrequently since not local
Recent admission to assisted living facility
Role execution Lost connections to neighborhood friends and recreation (regular
card games, lunch)
Greater supports for activities of daily living and instrumental
activities of daily living available in assisted living facility
Cognitive skills Intact
(continued)
13 Management of Double Incontinence: Urinary Incontinence in the Presence…
294
Box 13.2 (continued)
Treatment Plan:
The Advanced Practice Nurse (APN) initially obtained a urinalysis to screen
for the presence of a urinary tract infection and asked Bebe to complete a
3-day diary to identify patterns of bowel and bladder output and uid intake.
No signs of a urinary tract infection were detected; however, both the urinaly-
sis and diary indicated signs of dehydration. Six targets for intervention were
subsequently identied:
1. Medications: Constipation and fecal incontinence were addressed with a
drug holiday from psyllium until stools became soft and formed and
Bebe’s pattern of daily evacuation returned. A diuretic holiday was also
implemented for up to 1week with daily blood pressure monitoring by
staff of the assisted living facility.
2. Fluid intake: Bebe was counseled to increase her uid intake to a mini-
mum of 1.5 to 2 liters/day to address her symptoms of dehydration, consti-
pation, and urinary urgency and frequency. The APN worked with Bebe to
identify a uid intake protocol that incorporated her preferred beverages,
avoided known bladder irritants, and aligned with her usual schedule and
lifestyle.
3. Diet: Guidelines for a gluten-free diet were reviewed and the APN made a
referral to the facility’s dietitian to work on serving foods that aligned
more with Bebe’s health needs and preferences. Eating smaller amounts
more frequently (e.g., 5 to 6 snack-size meals/day) was discussed as a
strategy until Bebe’s normal appetite returned.
4. Physical Therapy: The APN referred Bebe to physical therapy for an eval-
uation of her gait, balance, adaptive equipment, and need for general
conditioning.
5. Social Work/Activity Therapy: Bebe was referred by the APN to the facil-
ity’s social worker and activities director to explore options for maintain-
ing the connections and activities that she enjoyed with her neighborhood
friends, joining the facility’s “Newcomers Group” for new residents, par-
ticipating in at least some of the congregate meals, and accepting invita-
tions to meet facility residents with similar backgrounds and interests.
6. Management of Incontinence: The APN trained Bebe in techniques to sup-
press urinary urgency, including deep breathing, distraction, and quick
contractions of pelvic oor muscles to alleviate bladder spasms. The APN
also helped Bebe to select an absorbent product that was more aligned
with the small amounts of urine and stool leakage that she experienced.
Prevention of incontinence associated dermatitis was also discussed and
an “all-in-one” product was recommended for cleansing, moisturizing,
and protecting the perineal and perianal areas.
(continued)
J. P. Robinson and S. J. Engberg
295
References
1. Kaplan S, Dmochowski R, Cash B, Kopp Z, Berriman S, Khullar V.Systematic review of the
relationship between bladder and bowel function: implications for patient management. Int J
Clin Pract. 2013;67(3):205–16.
2. Dumoulin C, Booth J, Cacciari L, Campbell P, Hagen S, Homsi Jorge C, et al. Adult conserva-
tive management. In: Cardozo L, Rovner E, Wagg A, Wein A, Abrams P, editors. Incontinence.
7th ed. Bristol UK: International Continence Society; 2023. p. 795–1038.
3. Botlero R, Bell RJ, Urquhart DM, Davis SR. Prevalence of fecal incontinence and its
relationship with urinary incontinence in women living in the community. Menopause.
2011;18(6):685–9.
4. Bliss DZ, Lewis J, Hasselman K, Savik K, Lowry A, Whitebird R.Use and evaluation of dis-
posable absorbent products for managing fecal incontinence by community-living people. J
Wound Ostomy Continence Nurs. 2011;38(3):289.
5. ICS Glossary: Double incontinence: International Continence Society; 2024. Available from:
https://www.ics.org/glossary/symptom/doubleincontinence.
Box 13.2 (continued)
Outcome:
Bebe was followed for 3months. Over time, her bowel and bladder patterns
returned to baseline, and she gradually recovered full bladder and bowel con-
trol though still wears a small absorbent pad “just in case.” She no longer
suffers from constipation or urinary urgency and frequency. She continues on
psyllium and a gluten-free diet and is now very intentional about maintaining
a uid intake of 2 liters/day to prevent constipation, urinary symptoms, and
dehydration. Bebe seldom experiences dizziness and has had no falls. Her
blood pressure remained within an acceptable range for the duration of the
diuretic holiday, which prompted an extension of the diuretic hold order for
several more weeks and an ultimate stop order when evidence of a rising
blood pressure failed to materialize. Weekly monitoring of Bebe’s blood pres-
sure by facility staff continues.
Bebe’s appetite improved though she does best with frequent snack size
meals, which the facility delivers to her room. She participates in congregate
meals once or twice/week, attended one or two meetings of the “Newcomers
Group” and has met several residents with similar interests and backgrounds.
With encouragement from the social worker, Bebe resumed connection with
several of her neighborhood friends by phone and arrangements are in prog-
ress for Bebe’s travel to a luncheon card party in her old neighborhood.
Following a course of physical therapy to improve mobility, strength and bal-
ance, Bebe relies less on her cane indoors and has improved stamina. She is
looking forward to a visit from her daughter in the coming weeks and looks
forward to “getting out around town” with her during the visit.
13 Management of Double Incontinence: Urinary Incontinence in the Presence…