Helping clients live positively with urinary incontinence
There are 3.84 million Australians who suffer the indignity of urinary incontinence – approximately 3.1 million (38.1%) women and 780,000 (10.2%) men.1 With these figures it is very likely that you have clients with this problem.
Urinary incontinence can be intractable and ongoing. You may have a client who is newly diagnosed. Or you may have assessed your client, carried out investigations, tried conservative therapies and possibly even surgery. You’ve tried everything and your client still has urinary incontinence and they are desperately looking to you for help and advice. If you feel you have nothing left to offer your client and you are thinking “... what now?” then this booklet is for you. In it you will find information that will enable you to help clients problem-solve and develop plans for living more effectively with urinary incontinence.
As well as providing treatment and therapy, health professionals have an important role to play in assisting clients to live with their condition and better manage it in their daily lives, regardless of where they are in the treatment trajectory. They play an important role in assisting clients to deal with the emotional impact of urinary incontinence, as they are sometimes the only people with whom the problem is discussed frankly. Rather than simply treat it as a nuisance,22 they can offer knowledge and support that can assist clients to problem-solve and develop plans for living more effectively with urinary incontinence. This will improve clients’ quality of life, minimise or prevent secondary problems and give them more control over their lives.
All people with urinary incontinence self-manage, but not always in ways that contribute to living independent and pleasurable lives. Research has shown that urinary incontinence has a major impact on physical, emotional and social health and wellbeing,2, 3, 4 including sleep problems,5, 6 psychological distress,7, 8 restrictions in physical activity,9 travel,10, 11 leisure, 12 work,13 relationships and sexuality.14 The consequences of urinary incontinence can include embarrassment,12 odour, social isolation,15 stigma16 and financial cost,17 and it can lead to institutionalisation18 and depression.19, 20, 21 Urinary incontinence can range from mild (for example, a few drops when coughing or sneezing) to severe (such as flooding without warning). However, the bother and impact of urinary incontinence is not simply related to severity. It depends on many personal characteristics such as age, gender, activity level, context (such as work situation), lifestyle and relationships. Very mild urinary incontinence can have a major and devastating impact on one person, while another with more severe incontinence may manage it with less stress.
This booklet does not provide information about available therapies and treatment options. However, as there are treatments and therapies that do much to help, it is important to refer clients who have not been clinically assessed to a continence specialist. There are also clinical guidelines available to facilitate clinical decision-making. For more information about resources, clinical guidelines and the role of continence specialists, see Appendix 1.
The information in this booklet is intended for health professionals who have an interest in urinary incontinence, but not necessarily specialist knowledge. It provides information to assist adult men and women with chronic urinary incontinence who are living independently in the community, when:
The strategies outlined in this booklet are based on an assumption that your patient can self-manage and self-toilet.
The information provided in this booklet draws upon research into self-management of urinary incontinence in the community conducted by a team from the Griffith University Research Centre for Clinical and Community Practice Innovation (the Griffith study).23 The Griffith study gathered information from three sources: surveys and interviews with adult men and women living with urinary incontinence in the community, a survey of continence nurse specialists, a review of the literature and a review of client continence education material on continence.
The Griffith study found that clients want good information about urinary incontinence and the prognosis of their condition. They also need an opportunity to discuss their feelings about their condition, the burden it creates in their daily lives, how they feel about themselves and better ways to self-manage. The review of client continence education material highlighted areas where further information is needed to support men and women in self-care.
Knowing which symptoms create the most problems for clients in their everyday lives is important. The Griffith study asked people living with urinary incontinence to indicate which problems they found most difficult to manage. They identified problems that people found most difficult were those that:
More specifically, men and women found it difficult to deal with going to the toilet frequently and having to rush, not knowing an accident is going to occur, having to deal with accidents away from home and managing odour problems. Women also found it difficult to manage leaking when coughing or sneezing, manage the cost of incontinence aids, and to find the right products for their needs.
Great energy is devoted to managing incontinence and normalising it into daily life. How urinary incontinence is managed may vary, but being in control remains an underlying theme. When confronted with an unexpected episode of incontinence, people tend to react immediately to avoid or reduce the chance that others will be aware of it. Fear of a recurrence becomes a driving force behind strategies used to manage incontinence.
A range of approaches are used to manage urinary incontinence in everyday living, which can be conceptualised as containing, concealing, restricting and modifying. These approaches are applied to everyday functions including: planning, routines, toileting, using pads and aids, adjusting fluids, body care and hygiene, physical activity and exercise and creating a more structured environment.
Containing strategies are usually the first reactive approach taken to manage urinary incontinence. Containment enables an incontinent episode to be managed by collecting urine via an absorbent product or collecting device. Containment provides a mechanism for managing expected or unexpected incontinent episodes or to provide a sense of security for those who are mainly continent, but fear an incontinent episode.
Containing strategies are usually personalised and depend on the severity and type of urinary incontinence, personal circumstances, age, activity level, social context and personal preferences. Containing incontinent episodes is important for achieving social continence (the appearance of continence in social settings), but does not address underlying incontinence problems or reduce the chance of an accident. For this reason, it is important that a full assessment is carried out and clients are provided with care that goes beyond just choosing the right continence product for their needs.
Concealing serves to disguise an incontinent episode by covering up the smell or the sight of wet clothing, furniture or any other object or activity that indicates incontinence. Many clues can point to incontinence and require concealment. The aim of concealment is that no one will be aware of an incontinent episode, even if it occurs in public. Concealing incontinence maintains social continence, a public identity and a person’s sense of dignity.
Secrecy and concealment are major preoccupations for those experiencing urinary incontinence. People will control information about their incontinence carefully,24 sometimes even keeping it a secret from close family and friends.25
Approaches used to conceal urinary incontinence are aimed at re-establishing normality quickly. With time and sometimes following very embarrassing experiences, people learn about their own condition, when accidents are likely to occur and ways to conceal the occurrence of accidents from others.
People tend to place restrictions on themselves to avoid anything that may contribute to episodes of incontinence. Restrictions can relate to social activity, travel, physical activity, fluid intake and choice of occupation, as well as intimate relationships.26, 27
Sometimes restrictions on social activity can be so major, they are life-changing.28 While some people are determined not to let incontinence change their lives,29 others will curtail social activity to the extent that they stop going out and become isolated.30, 31 Many will limit social outings to places where they know the location of toilets and stop going to places (such as the theatre) where they know it will be difficult to get to a toilet.32 People with urinary incontinence can restrict their social and intimate interactions to the extent that they choose not to enter into new relationships and avoid sexual intercourse and/or orgasm.33
Many physical activities have a direct relationship with urinary incontinence. Lifting, strenuous activity, sport (such as jogging and swimming) and standing for long periods are either avoided or modified to reduce the risk of urine leakage.34, 35, 9, 31 People also modify their intake of fluids such as caffeine drinks and/or alcohol, particularly when going out, prior to exercise or prior to bedtime to avoid nocturia (increased need to urinate at night).36, 32, 37, 38
Restricting approaches can have a profound impact on a person’s lifestyle, social activities and, possibly, their health. Further, some restrictions (such as reducing fluids) can have health impacts if continued over the long term.
Modifying strategies are used to normalise urinary incontinence into a person’s daily life. Rather than restricting themselves, modifying strategies enable a person to participate in everyday living activities. People modify exercises, diet and fluid intake, medications, sexual activity, toileting, social interactions, containing pads and devices, clothing and the environment. For example, there is some evidence that people who experience urinary incontinence will use medications as a strategy, either by varying the time they take them37 or by omitting them, particularly before going out.35
Modifying involves careful planning, particularly when out socially. Once people with urinary incontinence have developed modifying strategies that work for them, they can establish routines that give them some mastery and control over their lives.39 However, while some modifying strategies (such as decreasing fluid intake or modifying medications) may enable people to achieve social continence in an immediate situation, they may have a negative impact on health if practiced over the long term.
People manage their urinary incontinence differently in public and private contexts. In the Griffith study people clearly differentiated between the strategies they use at home and when out socially. For example, at home people will accept a greater chance of having an accident, by drinking more fluids or wearing lighter pads or no pads at all.
Social continence is more important to your clients than keeping to strict treatment protocols.23 The Griffith study showed that many people will often ignore common therapeutic advice (e.g. drinking more fluids) if social continence can be maintained.
Another finding from the Griffith study was that people continue to engage in activities that have an impact on incontinence if they are important socially. For example, people continue to go dancing and drink coffee and alcohol – activities that they know will contribute to incontinence.
Understanding your client’s personal needs, social context and lifestyle has important implications for providing advice. Rather than giving blanket therapeutic and daily living advice, health professionals need to provide more sophisticated advice that differentiates between private and public contexts and recognises people’s need to continue to engage in a full range of social activities.
Urinary incontinence is not an illness. Rather, it is a chronic condition or symptom. Although it may be treated by health care providers, it is largely self-managed.40 The self-management strategies discussed in this booklet are those that are used to integrate urinary incontinence into daily living, rather than those designed to treat or cure it.40 Daily-living self-management is integral to living with urinary incontinence and a client’s objective to stay ‘in control’ and maintain a normal lifestyle. Research shows that people who take control of their incontinence maintain a better quality of life.41 To address daily living needs, health professionals need to work collaboratively with clients, understand their perspective and incorporate daily living self-management principles into their practice.
Growing numbers of people live with chronic illness, placing a burden on healthcare services and spurring the development of new approaches to chronic disease management.42 Self-management is part of the solution, with programs in Australia and internationally revealing significant improvements in people’s quality of life, and equipping people with the knowledge, skills and confidence to better manage condition-related problems.43 A general definition of self-management is ‘the individual’s ability to manage the symptoms, treatment, physical and psychosocial consequences and lifestyle changes inherent in living with a chronic condition’.42 Self-management involves participation in activities that seek to create order, discipline and control, not only to manage the physical consequences of a condition, but also the emotional and social effects experienced in day-to-day life.44 These effects are mitigated by privileging the client’s perspective and adopting a client-centred approach where responsibility for health and wellbeing is shared between client and health care provider.45
Self-management education focuses on how clients perceive problems, rather than health professionals’ ideas about what patients should know and do.46 Working from the client’s perspective and understanding their social context is particularly relevant to managing urinary incontinence, because health professionals’ advice (e.g. timing of voiding, fluid intake) may conflict with clients’ actual self-management practices. Living with urinary incontinence is very personal and each person develops individualised strategies according to their lifestyle and cultural and economic circumstances. Treatment advice that does not take into account clients’ concerns and their need to normalise their condition and minimise lifestyle changes are destined to either fail or be ignored.
Throughout treatment it is important to also assess your client’s daily living needs and self- management regime and develop a collaborative action plan. Key factors that affect the efficacy of self-management include:
People who have more choice about how they manage their urinary incontinence are more likely to rate their management as effective.47
Motivation is a key component in developing a daily living plan. People’s desire for a particular outcome is an important precursor to achieving a goal. Establishing a client’s most important needs will identify areas they are most willing to change, remembering that an acceptable level of incontinence will differ among individuals.
Knowledge about their condition and urinary incontinence in general may improve how your client manages the condition and minimise the negative impact of restrictions that are used to maintain social continence. Knowledge of causes, triggers and remedial strategies is likely to help the client manage more proactively. Knowledge needs to be tailored to the individual’s needs.
A plan that acknowledges, incorporates and reinforces client preferences has the best chance of improving quality of life. A daily living plan (see Appendix 3) will document the goals and priorities of the client and outline ways to achieve those goals. It will also provide ‘special plans’ or ‘back-up plans’ for emergency situations or special circumstances.
The beliefs people hold about their incontinence will affect how they choose to manage their condition.40 Causal beliefs affect an individual’s sense of responsibility and efficacy toward changing behaviour. For example, if an older woman thinks her incontinence is the result of the immutable process of aging, she will be less likely to try to improve the condition. That is why it is important to dispel common myths associated with urinary incontinence that may lead clients to believe they have little power to effect change.
It is important to consider your client’s level of confidence to self-manage, their sense of self-worth, feelings of control over their condition and their ability to assume self-management tasks. Better self-efficacy will improve their ability to manage incontinence effectively, fostering useful coping strategies48 and improving their quality of life.41 It is important that health professionals consider how their relationship with the client can positively influence self-efficacy, as this will contribute to successful self-management.
Different aspects of your client’s life may impede or facilitate positive self-management of urinary incontinence, such as family, cultural background, employment and literacy levels. Religious, familial and cultural beliefs may also affect a client’s thoughts about self-management and the effectiveness of particular strategies.
When advising clients about daily living strategies to manage urinary incontinence:
A full range of concealing, containing, restricting and modifying strategies are used to plan and manage social situations. You can help your clients to develop individualised plans and strategies that will maintain social continence, taking into account daily living, work, physical and social activities. Help can be offered to assist clients as they work out their own individual ’systems’: plan outings, identify things to take with them when out, plan routines, garner support and manage special occasions. People with urinary incontinence can develop routines to reduce the chance of leaking in public, avoid situations where they cannot get to a toilet easily, plan activities for when they are less likely to leak and be prepared in the event of an accident.
Different plans and routines may be developed for home and social contexts. In particular, routines can be developed that reduce any negative effects of strategies used when out socially by balancing them with activities at home. For example, if fluids are restricted when out, sufficient fluids should be taken when at home.
A collaborative approach requires in-depth assessment so that plans and routines can be formulated and appropriate advice and teaching provided. Crucial topics to cover include toileting, fluids and diet, body care and hygiene, physical activity and exercise, strategies for social occasions and the use of pads and aids. This booklet will address each of these and provide specific assessment items and approaches to planning, advising and teaching. The booklet also provides some tips you may wish to share with your clients on these topics. Appendix 2 provides an overview of assessment guidelines related to daily living self-management of urinary incontinence.
When working with clients, try to plan individualised and manageable toileting routines that take account of daily living contexts and work, physical and social activities.
People use a range of toileting strategies to manage urinary incontinence in everyday living.
The toileting strategies clients are willing to use will vary depending on whether they are being used at home or out socially. For example, to maintain social continence, clients will often ignore toileting advice from health professionals and go to the toilet regularly or ‘just in case’ when out socially. Going to the toilet more often than others can attract attention, and research shows that this is given as a reason for non-attendance at particular social occasions (e.g. the football).49, 50, 51
When doing a general health and continence assessment focus on:
The literature suggests that for people with urge incontinence it may be better to delay voiding and to use distraction techniques when the urge occurs. However, many people with urinary incontinence will void ‘just in case’, so when developing plans for clients it may be necessary to discuss this issue.
Many clients lack knowledge about bladder structure and function, so it may be useful to include information to explain how this is altered by their specific condition.
Planning toileting strategies is important for social continence, so encourage clients to identify the availability of toilets and resources in the community. They will need different plans for how they manage at home compared to when they are out. Encourage them to practice toileting strategies at home before they use them when they are out to ensure they are effective.
|Normal situations||•||Go to the toilet at regular times (E.g. before going to bed, at regular intervals and after sitting for some time)|
|•||Take time to empty your bladder, relax and practice double voiding|
|•||When you get an urge to go to the toilet, practice putting it off by thinking about something else, sitting down, talking to someone or creating a distraction|
|•||Try out ways of staying dry at home to see if they work.|
|When out socially|
|•||Use the National Public Toilet Map to plan outings (see Appendix 1)|
|•||Wherever you go, work out where there are clean toilets you can get to easily|
|•||Find times when going to the toilet is less of an interruption|
|•||Choose an aisle seat at the theatre or when travelling|
|•||Holding on for too long can lead to an accident. Go to the toilet:|
- immediately before going out
- on arriving
- as soon as you get the urge
- before getting into a car to travel
|•||Work out where the toilets are as soon as you arrive somewhere new.|
|Risk of an accident|
|•||Women can use the closest toilets, even if they are men’s|
|•||Use disabled toilets and toilets in fast-food outlets and petrol stations|
|•||Carry a card to show people in toilet queues in an emergency: ‘I have a health problem and need to use the toilet urgently’.|
|Incontinence at night||•||Tighten pelvic floor; think of something else when experiencing an urge|
|•||Try setting the alarm clock at night for regular toileting to see if it helps.|
|Men||•||Sit down if you find it easier|
|•||Practice urethral/bulbar massage, especially if you dribble after you finish passing urine|
|•||If you’re embarrassed about using a public toilet (e.g. you have a slow stream) use the toilet cubicle instead of the urinal|
|•||Keep a container in the car for emergencies.|
People who experience urinary incontinence frequently modify or manipulate their fluid intake23 by increasing,37 decreasing34 or regulating the timing52 of fluid intake. For example, people may stop drinking for a period before going out or while out,49 may drink a lot at home but not when out, or restrict fluids in the evening prior to going to bed. People also modify the types of fluids they drink, reducing alcohol and caffeinated drinks,49, 35 or use nutritional or home remedy strategies such as vitamins, calcium, zinc, white willow bark, cherry juice and pickle juice.30, 29, 53
The Griffith study found that people only appeared to heed advice in relation to fluid intake amounts and type of fluid on some occasions. Common strategies to avoid leaking included reducing fluids, avoiding fluids when out socially and avoiding or stopping drinking fluids at a particular time in the evening. While older women sometimes eliminated caffeinated drinks, most working-aged women and men only rarely made changes in relation to alcohol and caffeine.
The recommended daily fluid intake is generally between 1500 and 2000 mls per day.54, 55, 56 However, evidence supporting advice about the role of fluid intake in relation to urinary incontinence is equivocal. One review concluded that fluid intake is not a direct cause of urinary incontinence, and that restricting fluid intake does not increase urinary incontinence frequency or severity, but that taking more than three litres per day may increase voiding and urinary incontinence frequency.57 Other studies have found no correlation58 between fluid intake and urinary incontinence, nor have they found that a decrease in fluids will improve symptoms in women with detrusor overactivity.59 Evidence shows that restricting fluid intake at night may improve urinary incontinence symptoms in older people; however, for people with low fluid intake, increasing fluids may improve urinary incontinence.60
Although there is debate about the amount of daily fluids that should be taken, there is consensus that clients need to maintain a minimum amount of fluid to support healthy urinary tract function and produce adequate urinary output. There is much debate as to what constitutes a minimum amount of fluid as this varies depending on organ function, activity levels, body temperature and ambient temperature. Clients with cardiac, renal or other conditions that may impact on fluid balance require medical assessment. Others can be reminded to drink more, observe their urine colour and smell and see their doctor if their urine is dark or has an unpleasant odour.
Health professionals commonly advise people to reduce caffeine and alcohol intake. Products containing caffeine include tea, coffee, cola drinks, chocolate and many energy drinks. Caffeine products contain three compounds: caffeine, theophylline and theobromine. These are part of a larger group of chemicals called methylxanthines that act as a natural diuretic. Caffeine also acts as a bladder irritant.61, 62 Physiological understandings suggest that caffeine exacerbates symptoms of urinary incontinence60 and that this effect may be compounded by the type of urinary incontinence. However, the effects of caffeine on bladder function have not been widely researched and results are mixed. Some reviews and research suggest that caffeine reduction education may help reduce urinary symptoms,63 that there is a relationship between caffeine and urinary symptoms,64 and that it may contribute to lighter sleeping patterns and increase sensitivity to bladder activity.54 However, others suggest that there is little evidence that caffeine contributes to diuresis.57, 65, 59
Patients are often advised to reduce alcohol, because it is considered a bladder irritant and can impair mobility and the perception of bladder filling. It can also result in increased urinary frequency and urgency. While some studies have suggested that alcohol use may increase irritative urinary symptoms66, 67 others have found no association between alcohol consumption and continence.68
Although there is limited evidence, other possible bladder irritants that have been suggested are citrus juices like orange, lemon or grapefruit juice, cordial, drinks high in sugar, carbonated drinks, and drinks with preservatives and artificial sweeteners. Anecdotal evidence suggests that sensitivity to these products is variable.
There is inadequate research on the relationship between food and urinary incontinence. However, anecdotal evidence suggests that certain foods such as artificial sweeteners, spicy foods and citrus fruits may act as bladder irritants, causing urgency, frequency and urinary incontinence,69 although no studies support advice to eliminate these foods from the diet. While cranberries have been advised for those with recurrent cystitis,54 and are advised by health practitioners to reduce odour,23 there is no evidence that they have any impact on urinary incontinence and, if taken in excess, they may contribute to kidney stones. As a result, any recommendation is best made on an individual trial basis, if at all.
Prior to providing advice about fluids, clients need to be individually assessed. Assessment includes:
Rather than providing general across-the-board advice for all clients, it is better to tailor your advice for each client based on individual assessment and circumstances. It is also important to acknowledge that most people with urinary incontinence will restrict fluids when out socially, because this contributes to social continence. Advice, teaching and planning can include:
|Amount||•||Drink when you’re thirsty|
|•||Drink extra fluids if exercising, the weather is hot, or urine is dark after the first void in the morning|
|•||Be aware that it’s possible to take too little or too much fluid|
|•||Avoid excessive amounts of fluid in a short time.|
|Type of fluids|
|•||Preferably drink water or drinks that are not high in calories, sugar, alcohol and caffeine|
|•||Substitute water for other drinks where possible|
|•||‘Pilot test’ fluids to identify if particular types of fluids cause problems (e.g. alcohol, coffee, tea, cola). If they are a problem, reduce or eliminate them, particularly when out socially|
|•||Drink water between alcoholic drinks|
|•||Cranberry juice may be helpful if you suffer from urinary tract infections.|
|If there’s a need to increase fluids||•||Set weekly goals|
|•||Start slowly, take time to increase amount|
|•||Drink a full glass of water instead of a half glass when taking medications|
|•||Drink when you’re thirsty, plus one more|
|•||If you don’t like water, drink water with flavours, juice or fresh lemon juice, or eat as ice blocks, jelly, custard or soup|
|•||Make an effort to increase fluids in warmer months|
|•||Consider herbal teas, chamomile, decaffeinated teas and lemon teas.|
|When out socially||•||Limit drinking before going out and while out|
|•||Limit drinking before activities that you know can cause accidents (E.g. travelling and playing sport)|
|•||If thirsty, take small amounts over a period of time|
|•||Watch for signs of dehydration.|
|Planning||•||Plan for fluid intake over a 24-hour period|
|•||Try altering the timing of drinks rather than the amount|
|•||Observe your patterns of fluid intake and output. Trial strategies with different types, timing and amounts of fluids when at home|
|•||Stop drinking at a particular time in the evening; don’t have an evening coffee or tea|
|•||If you drink alcohol, drink earlier in the evening|
|•||Drink a lot in the morning so that all your toileting is done then, before going out in the afternoon.|
Body care, hygiene and clothing strategies are all important ways for your clients to conceal incontinent episodes and control wetness, odour and skin problems. Getting it right helps to promote general health and self-esteem, as well as preventing complications.
The importance of good skincare in preventing skin breakdown is vital, yet no random controlled trials have examined the methods or products most likely to achieve this goal.70 Most of the evidence for wetness and odour self-care is derived from research and reviews related to skin care for nursing home residents with urinary incontinence. That said, there is a wealth of expert opinion that suggests that the key elements of an effective preventive protocol include using non-occlusive underwear, prompt and gentle cleansing and the use of moisturisers to replace lost lipids, as well as barrier creams for protection.71, 72
Absorptive products like pads can trap body heat and moisture, so these products should not be secured too tightly and underwear is best if made from non-occlusive materials.72 In addition, although there is no evidence that a less frequent pad changing routine has an effect on skin erythema or pH, there is certainly evidence that wet skin may make skin more vulnerable to friction and abrasion.71
The value of anti-microbial agents is unproven,72 so cleansers that are pH balanced and contain surfactants to lift irritants from the skin surface without scrubbing are suggested. Bar soaps and washcloths are abrasive and best avoided, as are soaps with added fragrance as they may contribute to allergic contact. The key ingredients in moisturisers are emollients to restore lipids.72 Although barrier creams can reduce the irritation of urine on the skin, some barrier creams can produce a barrier within absorbent pads, which can reduce their absorbent qualities and effectiveness. Dimethicone-based products, however, provide a non-occlusive barrier film that is non-greasy and easy to apply and remove.72 If persistent skin irritations occur, refer clients to a continence nurse specialist.
People often use deodorisers or frequent hygiene routines to conceal odours associated with incontinence.29, 33 The constant worry about the possibility of odour, or ‘body vigilance’,25 means that some people launder underwear, clothing or bedding frequently whether it is soiled or not, ‘just in case it smells’.30 The Griffith study found that women were more likely than men to change their pads frequently and use deodorisers, perfumes and creams to protect their skin. Working-aged women especially were likely to have more showers than usual. However, both men and women often washed clothes and bedding regularly, whether soiled or not, a practice that may require more clothes, underwear and bedding.
Clothes can act as a concealing backup. Wet patches may be visible on clothing and pads or aids may be bulky under trousers. The Griffith study found that working-aged women were the most likely to wear clothing that conceals accidents. People with urinary incontinence will wear dark coloured or patterned clothing to camouflage leakage. To cover leakage, women will wear skirts in preference to pants and generally both women and men will wear long jackets, use distraction, or carry something in front of them to conceal wet patches.
Longer-term body self-care strategies include weight control and bowel management. The Griffith study found that many people made sure their bowels were regular as a common strategy and that occasionally women attempted to lose weight.
Assessment of body care and hygiene needs can focus on:
As with all advice on incontinence, the key is to tailor information to your client’s particular needs and circumstances. When helping clients to plan short-term and long-term strategies for body care, skincare and odour management, differentiated advice can be offered for when clients are out socially and for when they are at home.
At home clients usually have fewer problems changing clothing and having a shower if an accident occurs. However, problems occur where there is inadequate access to facilities that allow for privacy, for example in work or social settings or among the homeless. Dealing with this topic requires sensitivity, tact, understanding and compassion.
Clients may not be aware that constipation and excess body weight can worsen symptoms of urinary incontinence, thus it may be beneficial to discuss these issues with your client and develop strategies to promote regular bowel habits and weight loss.
|General||•||Try clothing that’s washable, easy to launder and doesn’t require dry cleaning or hand washing|
|•||Choose clothes that are manageable, easy to remove and replace, easy to pull up and down and alows easy access to the perineal area|
|•||To maintain safety, avoid very high heeled shoes|
|•||Avoid clothing that increases abdominal pressure|
|•||To avoid odour, clean objects in the environment that are soiled (such as furniture and bedding).|
|•||To maintain safety avoid belts, buckles, tight waistbands, corsets and step-ins, trouser braces and complicated zips and fasteners|
|•||Choose fasteners that are easy to manage and use elasticised waistbands and Velcro fasteners, especially where there’s a loss of mobility. However, take care with fragile skin|
|•||Clothing may need to be modified to assist self-management.|
|Outer garments||•||Aim for loose-fitting, comfortable or wraparound clothing|
|•||Wear skirts rather than pants (women), although long pants and track pants are also recommended as they’re easy to manage|
|•||Choose clothing that’s suitable to use with pads and where pads are not visible or obvious|
|•||Choose clothing that’s dark, multi-coloured and patterned, as these hide accidents|
|•||Avoid skirts if pantyhose are worn, as these can be time-consuming to remove|
|•||Use a split skirt if confined to a wheelchair.|
|Undergarments||•||Use natural fibre undergarments next to skin, particularly cotton and soft wool|
|•||Use garments that are easy to pull up and down and are comfortable next to the skin|
|•||Avoid synthetics and satin|
|•||Choose undergarments that will be suitable to use with pads (e.g. purpose-designed pants, padded pants, pull-up pants, mesh pants, bike pants, stretch pants)|
|•||Choose undergarments that are comfortable, not too tight, yet firm enough to hold pads in place|
|•||Avoid many layers or double underwear, where possible|
|•||Use washable re-usable pants with disposable pads|
|•||If personally acceptable, don’t wear underwear to bed.|
|Personal hygiene||•||Establish a regular skincare routine|
|•||Use non-occlusive barrier creams and moisturisers, applied in a thin layer|
|•||Avoid fragranced skincare products as these may cause irritation|
|•||Change pads regularly, particularly in hot weather|
|•||Shower regularly and also, if practical, after an accident|
|•||As soon as practical, change soiled clothing and underwear|
|•||Carry moistened disposable cleaning wipes when out socially. Flushable wipes are available.|
Physical activity and urinary incontinence are clearly related. Activity impacts on incontinence and incontinence can affect a person’s ability to engage in activities. For example: the type and intensity of physical activity can initiate or exacerbate stress incontinence, particularly in women. Among men, greater physical activity at work such as lifting and heavy manual labour is associated with more urinary symptoms,73 and gait and strength training may improve functional incontinence.
To reduce the risk of leakage, people with urinary incontinence may restrict many of their physical activities including lifting, strenuous activity, sport (such as jogging and swimming) and standing for long periods.9, 35, 34, 74 They may also modify what they do. For example, while a person may continue skiing, an activity such as jogging may be replaced with walking, a gentler exercise that does not cause urine leakage.37, 75, 34 In order to improve bladder emptying, men can modify their voiding posture and sit rather than stand.38 People with urinary incontinence can also do pelvic floor exercises as a modifying strategy to control leaking34 or when in danger of leaking.23
The Griffith study found that although physical activities can be modified, many participants did not do this, perhaps because they did not want to, did not know how to or did not find it necessary. Furthermore, working-aged women and men rarely planned activities for when they were less likely to leak, and only working-aged women modified their activities.
Urinary incontinence can also have an impact on sexual activity. Research shows that many people will void immediately before sexual intercourse75 or use a towel during sexual activity for fear of incontinence.33 The Griffith study found that participants did not avoid having sexual intercourse or orgasm, or use different positions for sex, although working-aged women indicated that they sometimes passed urine before and after sex.
Assessment prior to providing advice about physical activity and exercise can include:
Wherever possible people with urinary incontinence are advised to continue exercising. There is a danger that fear of incontinence can lead people to adopt a more sedentary lifestyle. Clients may benefit from modifying exercise to include lower-impact activities that are consistent with their activity and lifestyle preferences. They may need to adopt containment strategies, such as wearing a pad, during exercise.
Pelvic floor muscle exercises (PFME) are advised for both men and women of all ages – particularly for pregnant women. It is often useful to tell older people that it is never too late to start PFME. Younger women with incontinence especially should be encouraged to start doing PFME and to continue them for the rest of their lives. However, as some conditions such as certain types of bowel dysfunction, overactive pelvic floor muscles, nocturnal enuresis and overactive bladder are worsened by pelvic floor muscle tightening, specialist assessment is required if the benefits are not quickly apparent. PFME should ideally be taught by a physiotherapist or specialist continence practitioner.
Encourage your clients to maintain healthy sexual activity. If there are difficulties they can seek medical advice or counselling – this is the case particularly for male clients who experience erectile dysfunction, as specific education can be provided about their specific incontinence condition and medications, and possible impacts on sexual function.
|General advice||•||Sit down to control urge incontinence|
|•||Tighten pelvic floor muscles if you think you’re in danger of leaking|
|•||Plan activities for when you’re less likely to lose control and are more rested, such as in the morning|
|•||Use a routine or a reminder for pelvic floor muscle exercises, particularly in a busy lifestyle (e.g. at meal times or when taking pills, place a cue in bassinet or on the fridge)|
|•||Go to the toilet before engaging in activity|
|•||Use suitable pads when doing impact exercises|
|•||Avoid activities that can increase or prolong abdominal pressure (e.g. heavy lifting)|
|•||Treat coughs and colds promptly.|
|•||Maintain exercise for general fitness|
|•||Continue to be as active as possible|
|•||Practice relaxation therapy|
|•||Modify the type of exercise you do from high impact (such as jogging) to low impact (such as walking)|
|•||Void prior to aerobics|
|•||Women: If only leaking with exercise, try using a tampon or specific vaginal device to support the anterior vaginal wall during periods of exercise.|
|Sexuality||•||Empty bladder before sex, particularly if incontinent during sexual intercourse|
|•||Empty bladder after sex, particularly women|
|•||Trial different sexual positions to see if there’s any impact on leakage.|
Social continence is all about living as normally as possible, enjoying social occasions and ensuring that urinary incontinence does not dominate life. The Griffith study found that people with urinary incontinence seek to manage leaking as a normal part of everyday life and ensure that their social activities are not affected by urinary incontinence. All participant groups continued to socialise outside close family and friendship networks and did not avoid new relationships, although older women occasionally limited business and leisure travel. Common strategies and approaches include toileting strategies and aids that enable clients to ‘normalise with protection’. The Griffith study indicated that health professionals can work with clients to plan special activities and events, such as going on an overseas trip, ballooning or attending a family wedding.
In order to plan social occasions it is important to assess not only severity and patterns of incontinence but also client mobility, levels of social participation and desired sexual activity. Specifically it may be necessary to assess the following:
Health professionals can work with clients to help them develop personalised plans and routines to reach their goals. Offer advice that helps maintain social continence and can be easily integrated into daily living patterns. Discuss strategies and plans to achieve and maintain social continence, including:
|General||•||Aim to prevent accidents rather than be required to cover them up|
|•||Be prepared to deal with an accident by taking spares and supplies|
- Plan activities for times when you’re more rested
- Plan how long you’ll be out
- Plan outings that’ll last only a certain period of time (e.g. going out for dinner for 2 to 2.5 hours)
- Make a plan for when you’ll go to the toilet during an outing
- Find times when going to the toilet is less of an interruption during an outing (e.g. when leaving a venue).
|Preparing for going out|
|•||Keep supplies in strategic places (e.g. car, workplace, golf bag)|
|•||Take back-up supplies where appropriate (e.g. spare pads, underwear and clothing, as well as bags for disposal).|
|Planning social activities||•||Learn where toilets are in your local area and in specific locations. Review the National Public Toilet Map (see Appendix 1) to find out where the toilets are, both on a journey’s route and at a destination. Identify the full range of publicly accessible toilets (e.g. parks, shopping centres, fast-food outlets and petrol stations)|
|•||Choose social occasions that are in locations with facilities (e.g. vicinity of toilets, access to privacy, access to pad or aid disposal)|
|•||Match social activities with who will be there (e.g. it is easier to say excuse me or pardon to friends than to strangers)|
|•||Be aware of triggers (e.g. if going to a restaurant with a fountain or running water, sit as far away from it as possible)|
|•||Take urinary incontinence medication before going out|
|•||Choose an aisle seat or a seat close to the toilets where possible (e.g. when traveling on a plane or at the theatre)|
|•||Choose pads and products that are appropriate for the occasion|
|•||Change pads immediately before going out|
|•||Choose accommodation that has an ensuite (e.g. if at a caravan park choose cabins that have their own toilet facilities or a caravan site that’s next to the toilets)|
|•||Test strategies at home before using them when out|
|•||Restrictions (e.g. to fluids) in one part of the day can be made up in another part of the day.|
and avoiding accidents
|•||Use public toilets, parents’ rooms or workplace showers to clean and freshen up after an accident|
|•||If you’re caught short and can afford it, buy new clothes from shops to replace the wet clothes you’re wearing|
|•||If you’re comfortable, develop a sense of humour about it and involve your family and friends in the funny side|
|•||Dispose of pads privately (e.g. if at a friend’s house use the main wheelie garbage bin rather than an in-house bin, use a public bin or take home soiled pads)|
|•||Try hiding fresh pads, aids and supplies in bum bags, toiletry bags or non-obtrusive calico bags.|
Pads and aids conceal as well as contain. Although absorbent products such as pads and pants are used by both men and women, they are more favoured by women,52, 76 with mini pads the most commonly used.77 Pad use has been reported at 17% for young women, 63% for middle-aged women and 74% for older women in Australia.9 Many other types of disposable and washable, commercial and personally developed urine-collecting and protective devices are also used.
Clinical decision-making is difficult due to the large range of urinary continence products available on the market72 and limited research into the effectiveness of those products. Studies to date indicate that laboratory tests into the capacity of pads bear little relation to actual performance and clients’ assessment of wet comfort. Findings also indicate that skin integrity, comfort and fluid absorption70 may be better maintained with disposables;78, 71 and that pads can leak due to ineffective application, fit, client posture, and the frequency, volume and rate of urine flow.79
It is worth bearing in mind that continuing use of pads can be very expensive and people tend to modify available products to suit their own requirements. They may:
People tend to identify the most appropriate pad or aid for their problem through a process of trial and error. Types can be categorised as follows:
In an emergency people use items at hand, including paper towels, tissue paper,37 absorbent cloth,74 cotton, handkerchiefs, chux and toilet paper.23, 36 Pad and aid technologies are always improving and new and innovative products continue to be released onto the market.
Decisions about the choice of continence pads or aids can be based on a comprehensive individualised assessment. The best product is the one that is the most effective for your client and their situation. To assess this it is important to know how much leakage occurs, how long the pad or aid will contain leaking and how frequently it will require changing. When going out for any length of time clients need to take extra pads in case they are detained, have an accident and/or need to dispose of used pads and aids.
Clients may also wish to try out a range of pads and aids at different times of the day and night to choose the most effective in relation to:
Following assessment in relation to pads and aids you can suggest that your clients trial a number of different products before they make a choice. Decision-making will involve consideration of cost, availability and convenience of products. Companies will sometimes provide samples for clients to try out.
|General advice||•||Choose a pad or aid that’s easy to manage|
|•||Wear firm-fitting underwear to hold pads or aids in place|
|•||Trial pads or aids at home before using them out socially|
|•||Choose a pad or aid that’ll absorb the amount leaked in particular situations. Use different sizes or types of pads depending on the activity or time of day|
|•||Use different aids or devices for at home and when out|
|•||Wrap or double wrap soiled materials in a plastic bag and wrap soiled material in newspaper for rubbish disposal|
|•||Take spare supplies when out socially|
|•||Choose clothing that makes pads and aids easy to manage|
|•||Use protectors on furniture and bedding.|
|•||Use sheaths or external catheters for long trips|
|•||Alternate use of pad and sheaths/external catheters|
|•||Use a wide neck urinal|
|•||Put urinal inside a bucket so it’s not so obvious.|
People with urinary incontinence can structure their environment to manage more effectively, particularly access to the toilet and ease of cleaning. Although a person’s ability to toilet themselves may be affected by individual factors (such as mobility), environmental factors can also contribute to incontinence. People may have normal bladder function, but become incontinent because they can no longer access or manage in the toilet. Those with urge incontinence can reduce their chances of having an accident if they have easier access to a toilet. Access to the toilet can be affected by proximity to a toilet and ease of use, and safety may be important at particular times, such as at night.
When reviewing possible barriers to easy toilet access discuss:
Clients can review their home environment and consider how able they are and how easy it is for them to manage. They can take into account their ability to manage the required washing and cleaning, including floors, furniture, bedding and clothing.
Clients may also wish to review their financial situation, the cost of planned strategies and their eligibility for support schemes.
Encourage your clients to review their home environment, particularly in regard to safe toilet access (particularly strategies for toileting at night) and ease of cleaning. Review eligibility for support schemes and, if appropriate, refer clients for financial assistance.
|Environmental modification||•||Use protectors for bedding and furniture|
|•||Use over-toilet chairs, raised toilet seats, handrails and grab rails to make getting on and off the toilet easier|
|•||For severe incontinence and large accidents use appropriate floor coverings for easy cleaning (e.g. tiled floors rather than carpet)|
|•||Choose furniture that is easy to clean.|
|Toileting at night|
|•||Use a washable non-slip mat on the floor next to your bed|
|•||Use a night light|
|•||Organise your bedroom to be close to the toilet|
|•||Swap sides of the bed to be closest to the toilet|
|•||If there’s frequent night toileting, sleep in a separate bed so that your partner is not woken|
|•||Men can use a urinal or bucket at night to reduce the risk of falls|
|•||Women can use a bedside commode or try a female urinal.|
|Cleaning||•||Clean regularly: identify products and routines that will make cleaning quick, effective and easy|
|•||Clean any spills quickly to reduce the risk of odour and falls|
|•||Wash bedding regularly|
|•||If appropriate and affordable, use a cleaning or laundry service.|
|Costs||•||Review eligibility for support schemes (see Appendix 1)|
|•||Use cheaper pads and products at home and save more expensive pads and products for when out.|
Because urinary incontinence attracts great social stigma and is commonly associated with ageing, it has a major impact on how people feel about themselves. Younger people with incontinence often confront their own perceptions of urinary incontinence as an older person’s condition. As a way of normalising it, people tend to reconceptualise it (e.g. ‘It’s not a problem if it happens at home’), deny its importance or rename it (e.g. ‘I just leak, I’m not incontinent’) or simply ignore it, re-establishing normality by clearing up immediately.25 They can modify their expectations by redefining what is considered ‘wet’ and ‘dry’.38 People with urinary incontinence may revise their private identity by learning about anatomy and physiology, family history and life events and rejecting cultural attitudes toward urinary incontinence.80
Those experiencing urinary incontinence seek to conceal episodes and control who has information about their condition, often restricting this information to close family or never sharing it. However, the literature indicates that close friends and same-sex family members may share the secret and be recruited to assist in management strategies.80 The Griffith study also found this, but showed that most people coped with urinary incontinence alone, keeping accidents a secret and mostly not discussing their condition with close friends and family. In the case of an accident, older women and men sometimes used humour or positive thinking, while working-aged women indicated that they rarely did this.
It may also be useful to clarify clients’ perceptions of their condition. Before designing educational strategies you will need to assess a client’s knowledge about their condition. Teaching strategies will vary according to your client’s learning style. In particular it is useful to determine if your client would prefer access to individual or group sessions, reading materials, internet sites or other available media.
Client self-esteem and availability of emotional and social support are important considerations.
Clients need an opportunity to discuss their feelings about their condition and the burden it creates in their daily lives and how they feel about themselves. Furthermore, people with incontinence need to develop a way of integrating the condition into their sense of self, while maintaining dignity and self-esteem.
Health professionals play an important role in providing clients with information about urinary incontinence, helping them understand their specific condition, facilitating access to social support and providing an opportunity to discuss the emotional impact of managing urinary incontinence in their daily lives. Points of discussion can include:
|Improving self-esteem||•||Do things that make you feel good about yourself|
|•||Pamper your body (e.g. with massages or warm baths)|
|•||Choose clothing that makes you feel attractive.|
|Reframing the way you think about your problem|
|•||Acknowledge that urinary incontinence is a very common problem, experienced by men and women, old and young.You are not alone|
|•||Seek help to gain information and achieve an improvement or cure|
|•||Make plans and routines just a part of your life|
|•||Focus on making sure you can do the things you want to do|
|•||See the funny side.|
|￼Improving knowledge about your condition||•||Access information about urinary incontinence (e.g. from health literature, health professionals or the Continence Foundation of Australia – see Appendix 1).|
|Getting support||•||Identify someone close and trusted with whom you can discuss the problem|
|•||Request assistance and understanding from relatives and close friends if needed|
|•||Discuss your condition with close family and/or friends so that they understand about accidents.|
Clients can be referred to appropriate continence specialists for comprehensive assessment, treatment, management and therapy. Information, support and advice can be gained from a range of health professionals, literature, organisations and websites.
The care of people with urinary incontinence is increasingly seen as a prime example of how a multidisciplinary team approach can achieve far more than sequential referral from one health professional to another. Many different health professionals may be involved in the care of a person with urinary incontinence, particularly medical practitioners, physiotherapists, occupational therapists and nurses. Other health professionals who may provide input are social workers and dieticians.
In recent years commentators have suggested that an integrated multidisciplinary service model can deliver the best results for people living with urinary incontinence.81, 82, 83, 84, 85, 22, 86, 87 A nurse-led multidisciplinary clinic with multi-referral linkages to a further range of health professionals was evaluated in Queensland Australia.88 This model of care was found to be both rated highly by clients and effective in reducing incontinence.88 Practitioners working in such systems of service delivery can call upon a range of conservative management strategies and refer people with intractable problems for more invasive interventions.
In many Western countries general practitioners (GPs) or family physicians are the initial point of access to the health care system (such as in Australia, the United Kingdom, the United States and Canada). GPs play a primary care and referral role for patients presenting with urinary incontinence. However, research suggests that despite the high prevalence of urinary incontinence, especially in women, only about one-quarter of women consult their GPs about their symptoms.89, 90, 91, 92, 93 Moreover, GPs are often not likely to ask their patients questions about urinary incontinence.94
Despite this trend, the current consensus is that GPs are in an excellent position to assist clients in managing their urinary incontinence, by offering conservative management strategies and early treatment of symptoms. Many studies have shown that conservative management strategies (such as bladder training programs, pelvic floor muscle exercises and clean self-catheterisation) may be highly effective in the treatment and management of urinary incontinence and that earlier treatment of less severe symptoms is likely to prevent incontinence from getting worse.95 Studies suggest that when women find urinary incontinence bothersome they will seek medical help, and that the focus for GPs should be on accurate diagnosis and implementation of an evidence-based treatment plan.95
Medical practitioners in a range of specialties, such as urology, obstetrics and gynaecology, and geriatrics, provide specific treatments, therapies and surgery related to the conditions that contribute to urinary incontinence.
Physiotherapists have long played a role in the care of patients with urinary incontinence,96 specialising in the pelvic floor and assessment of pelvic floor strength, endurance of contraction and bladder functioning. They will develop a detailed plan of exercise and activities to improve continence including pelvic floor muscle exercises, bladder retraining, electrical stimulation and biofeedback, most of which have been shown to be effective in reducing incontinence.97, 98, 99, 100 More recently physiotherapists have been pioneers of multidisciplinary approaches to continence care101 and have been involved with development of continence care programs that are both evidence-based102 and customer-focused.103
As continence care has become increasingly multidisciplinary, the role of the occupational therapist has also developed.104, 105 In particular, occupational therapists work with clients who have functional incontinence, helping them to acquire skills or to adapt the environment so that they can manage their incontinence better.106
Nurses have always been involved with the management of incontinence in all settings and clinical areas. In 1974 with the rise of the clinical nurse specialist role, the role of the Nurse Continence Advisor (NCA) was developed107, 108 and by the 1990s the NCA role was acknowledged as pivotal to the management of incontinence.108 In countries with national health services, such as the UK and Australia, some nurses assess clients for the provision of incontinence products. These nurses need to be distinguished from NCAs who, with specialist knowledge, provide a range of interventions based on comprehensive assessment and care planning.109 The role of the NCA includes: clinical practice, comprehensive assessment, consultation, education, management and research,176 as well as the implementation of prescribed anticholinergic medication protocols, and referral.110, 111, 112, 113, 114
A variety of research studies, from large scale surveys to smaller randomised controlled trials, have found the NCA to be both effective and efficient in the management of urinary incontinence.115, 116, 117, 118, 119 A major study conducted in Australia found that the reduction in urine leakage and improvement in quality of life observed in patients with mild and moderate urinary incontinence treated by NCAs and urogynaecologists were similar at 12 weeks and two years, but with lower costs accrued to services provided by NCAs when compared to urogynaecologists. In addition, patients reported that the informal, friendly approach of nurse continence advisors decreased embarrassment and anxiety, providing patients with confidence and improving satisfaction with care.120
Advice about funding schemes is available from the National Continence Helpline on 1800 33 00 66, including:
State government schemes that provide incontinence aids vary widely. The criteria used to determine if your client is eligible and the products available are different depending on location. To find out what assistance may be available, contact the following state branches of the Continence Foundation of Australia (CFA):
|CFA Victoria||(03) 9816 826|
|CFA New South Wales||(02) 8741 5699|
|CFA Queensland||(07) 3876 7272|
|CFA Western Australia||(08) 9386 9777 or 1800 814 925|
|CFA South Australia||(08) 8266 5260|
|CFA Northern Territory||(08) 8922 7283|
|CFA Tasmania||(03) 6222 7303|
|CFA ACT||(02) 6205 1350|
The following clinical guidelines and statements are available to help clinicians with decision- making related to continence care:
Please note that these assessment guidelines are related only to daily living self-management and are not intended to be a comprehensive continence assessment.
Not at all
|Physical activities (e.g. sport, leisure)|
|Travel for more than 30 minutes|
|Going away on trips|
|Feelings about myself|
What have I stopped doing because of my leaky bladder?
When am I most likely to have an accident?
What bothers me the most about the impact of my leaky bladder?
What strategies do I currently use to manage my leaky bladder and how well do they work?
What do I find most difficult to manage?
What daily living activity would I most like to improve? (E.g. travelling, exercise, work, leisure and special events)
What are the barriers to achieving this change?
What are my aims? (E.g. a special occasion, holiday, activity)
Resources I can access
• Short term
• Medium and long term
Planning, preparation or changes I need to make
Strategies to try out at home
Outcome of trials or dummy runs
Equipment and supplies
Things I need to discuss with my health professional
Published by Australian Government Department of Health and Ageing
Copyright © 2007 Research Centre for Clinical and Community Practice Innovation, Griffith University, Gold Coast campus, Griffith University, Queensland, Australia, 4222 Parklands Drive, SoUthport, Queensland, Australia 4215
This booklet is intended for use by health professionals who have appropriate health care expertise. The applicability of any information must be established before relying on the information in this booklet. While care has been taken to ensure that the information in this booklet summarises available research and expert consensus, any loss, damage, cost, expense or liability suffered or incurred as a result of reliance on this information (whether arising in contract, negligence or otherwise) is, to the extent permitted by law, excluded.
Associate Professor Winsome St John
School of Nursing and Midwifery, Griffith University
Research Centre for Clinical and Community practice Innovation, Griffith University
Professor Marianne Wallis
Chair, Clinical Nursing research, a joint appointment between Griffith University and the Gold Coast Health Service District
Research Centre for Clinical and Community practice Innovation, Griffith University
Ms Shona McKenzie
Nurse Practitioner - Continence, Royal Brisbane Hospital
Ms Susan Griffiths
Research Centre for Clinical and Community practice Innovation, Griffith University
This project was funded by a grant from the Australian Government Department of Health and Ageing, National Continence Management Strategy.
Thanks are due to continence nurses belonging to Australian Nurses For Continence (ANFC), who provided information about advice they give their clients; the reference panel, who provided their expertise (Dianne Neilson, Heather Miller, Audrey Burgin, Christine Leech, Janie Thompson, Rosemary Mahomad, Carolyn Ehrlich, Charmaine Bryant and Jenny Nucifora); and people living with urinary incontinence who gener- ously shared their experiences and ideas.