Effects of Continence in Children Essay

Urinary incontinence (UI) is the involuntary loss of urine from the bladder (Keilman, 2010). The International Continence Society (ICS) defines the condition as a complaint of involuntary leakage of urine (

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Prevalence and Impact of UI
UI is a debilitating condition and can be quite distressful. The condition becomes more prevalent as the population ages; therefore, extremely common among the elderly (Abrams, 2002). UI is also twice more common in women than in men and has a prevalence ranging from about 20% in women aged 45 years or younger to about 30% in women aged 80 years or older (Landfeld, 2008). The prevalence increases with age with more than one-third of women older than 65 years of age experiencing some degree of UI; and about 12% reporting daily urine leakage (Kincade, 2007). It impacts life both physically and psychologically. In Australia specifically, UI affects about 13% men and 37% women (Australian Institute of Health and Welfare, 2006). Interestingly, about 70% of people do not seek consultation and treatment for their problem (Millard, 1998). Around 77% of nursing home residents in Australia are affected by the condition (Steel, 1995). The condition is associated with an increased utilization of health and social care, likelihood of institutionalization and considerable co-morbidity such as skin rashes, skin infections, depression, and urinary tract infection (Gadgil, 2008). In addition, most cases of UI are associated with the need for frequent, urgent trips to the bathroom. This particularly has been related to an increased risk of falls and fractures (Gadgil, 2008). UI sufferers suffer from feelings of embarrassment and anxiety. They have a decreased participation in social gatherings (Wyman, 1990). Moreover, there is associated financial burden in the form of cost of absorbent pads, treatment of the condition itself and its complications, and admissions to institutions. Thus, it proves to be a costly health problem particularly for women (Nygaard, 2007). The estimated costs are on rise causing excessive burden on patients and health care system. A study observed two – fold greater risk of nursing home admissions among women with UI compared to those without UI (Thom, 1997).Effects of Continence in Children Essay

Types of UI and its Risk Factors
UI can be of several types, most common of which is urge UI and stress UI; or it can be both in the form of mixed UI. It can also be functional or overflow type, though these are not very common.
Urge UI – This is also termed as urgency incontinence or overactive bladder or even reflex incontinence. This is the primary cause of UI in older people. Urge UI can be due to over activity of the detrusor muscles of the bladder. Detrusor over activity is characterized by involuntary detrusor muscle contractions during the filling phase. It may have a neurogenic cause or can be idiopathic, but in majority of the cases, the cause is unknown (Santiagu, 2008). Parkinson disease or stroke may cause a loss of inhibitory neurons; leading to neurogenic detrusor over activity. Even if the bladder is not full, involuntary bladder contractions can occur. This leads to symptoms of urgency and frequency (Santiagu, 2008). Another risk factor that leads to urge UI is nocturnal polyuria that is defined as producing more than 35% of the total daily urine output at night. This is again a problem associated with later life. Changes in kidney physiology result in kidneys working harder at night to produce greater quantities of more dilute urine. This can lead to increased urgency of urination in the nights (Gadgil, 2008).Effects of Continence in Children Essay
Stress UI – It is the involuntary leakage of urine during exertion or activities that increase intraabdominal pressure. The risk of this condition increases after pregnancy and after a vaginal delivery with a higher prevalence around menopause. Smoking and obesity are also some of the risk factors. The condition is due to weakness of the pelvic floor or sphincter. Several other risk factors may also be responsible that include postmenopausal involution of the urethra or as a complication of pelvic surgery or trauma (Santiagu, 2008).
Mixed UI – This type of UI is a combination of stress and urge UI where there is involuntary leakage with urgency and also with exertion, sneezing or coughing (Vasavada, 2013).
Functional UI – this type of UI is due to reasons other than neuro – urologic and urinary tract infections. The cause of this could be psychiatric disorders, delirium, or reduced mobility (Vasavada, 2013).
Overflow UI – This type of UI is caused by a hypotonic bladder, bladder outlet obstruction, or other forms of urinary retention. It results in lower urinary tract infection associated with loss of small amounts of urine. It is more common in men with benign prostatic hyperplasia (BPH) (DeMaagd, 2011).Effects of Continence in Children Essay

Nursing Interventions
Nurses are always at the fore front of any medical care. They are in a pivotal role to try and decrease the direct and indirect costs due to UI through health promotion. The aim of treatment that a nurse can offer for UI is to reduce symptoms and improve the overall QoL. A nurse plays a vital role in educating the patient on lifestyle interventions, particularly weight loss and physical activity in morbidly obese patients (Santiagu, 2008). It helps reduce stress UI, and to a certain extent, urge UI too. Caffeine restriction may also reduce UI. Constipation and straining during defecation may increase the risk of pelvic organ prolapse leading to stress UI. Therefore, training the patient on pelvic floor exercise that involves strengthening the pelvic floor muscles helps to an extent. It needs to be continued for 3-4 months before determining its success. Bladder training is the initial treatment for UI, being noninvasive, inexpensive, and easy to perform. This includes a scheduled voiding program with gradual increases in the duration between voids, and urge suppression techniques with distraction or relaxation (Santiagu, 2008). A Cochrane review suggests bladder training may be more effective than placebo (Wallace, 2000). The practice of conservative management of UI is generally beneficial and effective; and needs to be encouraged. Nurses understand better, the efficacy and significance of lifestyle adjustments, behavior modifications, and non-pharmacologic interventions.Effects of Continence in Children Essay

Implications for Nursing
With an increasing aging population, nurses can expect to see more people with UI and will have to become experts in providing quality and safe care to the aged. Understanding the situation of older people with UI and demonstrating care and concern is paramount in promoting QoL in this population. Therefore, timely and adequate education is crucial in the management of the condition (Keilman, 2010). It helps dispel perceptions and impacts compliance. Empowering older people through knowledge is in the hands of holistic nursing practice. Nurses certainly can make a difference in the management of the condition if they are aware of the essentials. The single most important action that a nurse can take is to ask every older adult about UI and then to follow the basic approaches to evaluation and management. If nurses spent quality time with UI sufferers, it is a significant observational clinical experience to them (Keilman, 2010). Ideally, the approach to UI should be from an interdisciplinary perspective where the nurse is ideally situated to practice holistically and provide the educational environment conducive to older adult learning. UI is the problem of the aged and with increased life expectancy, the people of the world are aging, thus making UI a global health concern that is here to stay (Keilman, 2010).Effects of Continence in Children Essay

My views
As a nursing student, caring for patients with UI is a part of my everyday course. I am beginning to be aware of the extensive problems that an adult with UI has; and the effect of these problems on their overall QoL. Beyond the usual social and psychological problems, I have also noticed several other issues such as admission to nursing homes, poor general health and well-being, and cognitive impairment too, which may be a part of aging. I find it very necessary to have the knowledge and skills necessary to improve upon the outcomes for UI patients.
Generally, most older adults who experience UI also experience fecal incontinence. It is embarrassing to most of them to openly talk about their suffering; therefore, the treating physician needs to proactively enquire about any other symptoms when patients reports UI. Some feel they should tolerate their symptoms rather than shamelessly reporting it. For such reasons, UI goes unreported, and therefore, untreated. The way consequences like social stigmatization and isolation manifest itself is different for each patient and this should be taken into account when carrying out an individual and holistic continence assessment.Effects of Continence in Children Essay
I understand a need to improve upon my knowledge of local policies and protocols; and about services available to patients with continence problems. I would also like to improve my understanding of quality of life assessments. I intend to gain knowledge on National Institute for Health and Clinical Excellence’s (NICE) guidelines for continence care so that I can complete a more in-depth assessment of patient needs.

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Bladder and bowel control problems are common. More than four million Australians regularly experience leakage from the bladder and bowel (incontinence). Many others have bladder and bowel control problems, such as needing to go to the toilet more frequently and an urgency to go without leakage. Together, these problems are often called continence problems.

Although incontinence and continence problems have a considerable impact on a person’s quality of life, many people do not seek help. Embarrassment often prevents people talking about their bladder and bowel problems. Some people restrict going out and have little social contact outside their home.Effects of Continence in Children Essay

There is no need to become a recluse. The good news is that for most people, these problems can either be cured or at least better managed. You can lead a normal life without needing to plan your activities around the toilet.
Incontinence and continence problems are common
Incontinence and continence problems affect people of all ages, gender, cultures and backgrounds. Despite popular beliefs, older people are not the only ones affected.

Some incontinence facts include:
One in three women who have had a baby experience loss of bladder control.
One in five children wet the bed at some time.
One in 100 adults never achieve bladder control at night.
One in 20 adults experience bladder and bowel control problems.
Bladder and bowel control problems are not an inevitable part of ageing. Visit your doctor to discuss treatment and management options.Effects of Continence in Children Essay
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Continence problems and bladder or bowel issues
Incontinence and continence problems are symptoms of bladder or bowel dysfunction. They tell you that something is not quite right. Pelvic floor muscle weakness is a common cause of these symptoms. Changes to the nerves controlling the bladder, bowel or pelvic floor can also result in loss of control.

Sometimes, other health problems such as diabetes, stroke, Parkinson’s disease or multiple sclerosis can cause bladder or bowel control problems.
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Symptoms of bladder continence problems
People with bladder control problems may experience:
leaking urine with coughs, sneezes or exercise
leaking urine on the way to the toilet
passing urine frequently
rushing to the toilet (urgency)
getting up twice or more at night to pass urine
wetting the bed when asleep
feeling their bladder is not completely empty
having poor urine flow
straining to get the bladder to empty
frequently having urinary tract infections (UTIs).Effects of Continence in Children Essay
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Symptoms of bowel continence problems
People with bowel control problems may experience:
leaking from the bowel with the urge to open their bowels
rushing to the toilet and feeling the need to urgently open their bowels
leaking from the bowel without the urge to open their bowels
leaking from the bowel on passing wind
being unable to control wind
straining to empty their bowels.
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Types of bladder control problems
Urinary incontinence and continence problems may include:
stress incontinence – leakage of small amounts of urine with exertion. Causes include childbirth, being overweight and prostate surgery
urge incontinence – leakage following a sudden urge to urinate. Causes include stroke, enlarged prostate gland and Parkinson’s disease, but often the cause is unknown
overflow incontinence – leakage because the bladder does not empty well and overfills. Causes include multiple sclerosis, an enlarged prostate gland and diabetes
functional incontinence – leakage of urine because a person was unable to get to or use the toilet due to a physical disability, a barrier in their environment or because of an intellectual or memory problem. Causes include dementia and poor mobility.Effects of Continence in Children Essay
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Types of bowel control problems
Bowel problems have many causes and may result in:
diarrhoea – frequently passing loose bowel motions. Causes include infection or bowel conditions such as Crohn’s disease and ulcerative colitis.
constipation – passing hard, dry bowel motions (with difficulty or straining). Causes include not drinking enough fluid, eating a diet low in fibre and lack of exercise.
faecal incontinence – an uncontrolled loss of a bowel motion. Causes include diarrhoea and constipation. It can also result from a problem in the lower bowel or anus, making it difficult to hold onto a bowel motion. Causes include childbirth and nerve problems such as diabetes.
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Treatment for incontinence and continence problems
If you have incontinence or continence problems, you should seek help. There is a range of management options available. The treatments depend on the type of incontinence you have and what you hope to achieve.


An incontinence management plan will usually include several of:
adequate fluid intake of up to two litres (6 to 8 glasses) each day (your urine should be pale yellow in colour)
a diet rich in fibre (such as wholegrain bread, cereals, fruit and vegetables) to prevent constipation
a pelvic floor muscle exercise program Effects of Continence in Children Essay
a bladder retraining program
a toileting program
incontinence aids such as pads, condom drainage or catheters.
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Prevention of incontinence and continence problems
There are things you can do to help keep your bladder and bowel healthy, and avoid incontinence and continence problems.

Suggestions for healthy lifestyle choices include:
Drink plenty of fluid – up to at least two litres (six to eight glasses) each day, unless your doctor advises you otherwise.
Eat well to prevent constipation and to maintain a healthy body weight – eat plenty of wholegrain foods (such as porridge, brown rice, wholemeal pasta, wholemeal bread, or pulses – lentils and beans) rather than highly processed or refined food and at least two pieces of fruit and five serves of vegetables every day.
Exercise regularly (at least 30 minutes every day) to keep fit and to prevent constipation.
Tone up your pelvic floor with pelvic floor exercises for good bladder and bowel control.
Practise good toilet habits to prevent bladder and bowel control problems.
Good toilet habits can help to prevent incontinence and continence problems. These include:
going to the toilet to pass urine only when you have the urge to go – don’t go ‘just in case’
taking time to completely empty your bladder and bowel
not delaying going to the toilet when you have the urge to use your bowels
using the correct posture on the toilet to help you pass a bowel motion (place your elbows on your knees, bulge out your stomach, straighten your spine and put your feet on a footstool (if it is safe to do).Effects of Continence in Children Essay

Pediatric UTI’s are a major health care problem. Urinary tract infections (UTIs) affect 3% of children every year. Annually, pediatric UTI’s account for over 1 million office visits in the U.S. (0.7% of all physician visits by children). Furthermore, each year there are approximately 13,000 pediatric admissions for pyelonephritis, with inpatient costs exceeding $180 million. Throughout childhood, the risk of UTI is 8% for girls and 2% for boys. Sexually active girls experience more UTIs than sexually inactive girls. However, during the first year of life, more boys than girls get UTI’s, with a tenfold increased risk for uncircumcised compared to circumcised boys.Effects of Continence in Children Essay

Clinical Presentation
The anatomic location of the UTI is germane to etiology and clinical presentation. Regardless of UTI location, infants and many young children cannot describe their symptoms; hence it is critical to understand the observable signs and symptoms of infection to make the diagnosis. Lower UTI’s include bladder infections (cystitis), whereas upper UTI’s include pyelonephritis and perinephric and renal abscess. Cystitis is second in frequency only to respiratory infection as a reason for pediatric medical visits. Classic symptoms of cystitis include urinary frequency, urgency, dysuria, hematuria, suprapubic pain, sensation of incomplete emptying, and often, even incontinence. Non-specific symptoms can include poor feeding, irritability, lethargy, vomiting, diarrhea, ill appearance, and abdominal distension (Table 1). Fever and flank pain are unusual symptoms for lower UTI, but fever can more often be a sign of lower UTI in children as compared to adults.Effects of Continence in Children Essay

Life is a one-way street and as people make their journey, they will encounter various obstacles they must face. The first steps on this path, which take years, are full of changes; this means that this stage of childhood is considered in many cases as new as it is worrying1. One of the best resources to solve the doubts that may arise to the youngest of the house is the use of reading.

The use of books, in addition to being an object of entertainment, can be a useful tool to help in various processes among which the healing process is. The fact of healing through books was first described by S.M. Crothers in 1916 under the term “bibliotherapy” in an article published by “The Atlantic Montly”; although the truth is that reading has been present in different times and places throughout the history of civilization2.Effects of Continence in Children Essay

Thus, in ancient Egypt, Pharaoh Ramses II grouped certain books of his library under the motto “Remedies for the soul” and in Rome, Aulo Cornelius Celso associated reading with medical treatment. In the same way, the Greeks used books as a medical and spiritual therapeutic tool. In the late eighteenth century, Pinnel in France and Tuke in England began to offer books to heal different types of ailments. The doctors of the nineteenth century, on the other hand, said that reading was one of the best methods to optimize the situation of inpatients2-3.

Another significant advance of bibliotherapy took place at the beginning of the 20th century, in the year 1930, when some libraries began to offer lists of books adapted to the characteristics of each person 3. In 2010 a list of books was created under the term “Compassion Books”, with the idea of ​​offering books that try to heal, through the care of the soul, the pain suffered by the body2.Effects of Continence in Children Essay

Despite the fact that endless benefits have been associated with bibliotherapy, this technique goes beyond the simple fact of reading stories. Therefore, it is necessary to choose adequately the works that fit each personal situation and combine these stories with reflection, as only in this way will the desired effects be achieved1,4.

In this way, the same book will not be offered to a healthy person or one suffering from a particular ailment, nor to an adult or a child. In the case of the youngest, the stories are the axis of bibliotherapy

Table 1. Symptoms of a Pediatric UTI
Lower Urinary Tract

Classic Non-specific Frequency Poor appetite Urgency Irritability Dysuria Lethargy Hematuria Vomiting Incomplete emptying Diarrhea Incontinence Abdominal distension

Upper Urinary Tract

Classic Non-specific Fever Poor appetite Flank pain Irritability Dysuria Lethargy Hematuria Vomiting Frequency Diarrhea Urgency Abdominal distension Effects of Continence in Children Essay

Pyelonephritis, and to a lesser degree renal abscesses, typically begin as a lower UTI that proceeds to an upper UTI as the infections ascends. However, pyelonephritis and renal abscesses can also result from hematogenous spread of infection (e.g., bacteremia). Symptoms that occur with upper UTI’s overlap those for cystitis, in part because cystitis is common in both. In upper UTI’s, flank pain and fevers (typically intermittent pain and >39°C) are more pronounced and important (Table 1).

Fungal and Viral UTI
Fungi and viruses can also cause cystitis in certain settings and with associated risk factors. Fungi are the second most common cause of nosocomial UTI in children, and can spread systemically and can be life-threatening. Risk factors for fungal UTI’s include the use of invasive devices (peripheral and central vascular access lines, drains, catheters), previous broad-spectrum antibiotic exposure, and systemic immunosuppression. A true candidurial infection can be difficult to diagnose, since it can represent colonization, contamination, or infection, and may or may not have associated symptoms. Suggestive diagnostic criteria include: Lack of pyuria and > 10 colony forming units/mL (in neonates) from a urine culture obtained by urethral catheterization. The potential for candiduria to develop into invasive candidiasis in the neonatal intensive care unit (NICU) is significant. Risk factors for this progression include prematurity, congenital urinary tract abnormalities, parenteral nutrition, respiratory intubation, and umbilical artery or intravenous catheterization. Furthermore, the kidney is the most commonly affected organ in candidiasis, with “fungus balls” in the renal pelvis/calyces, representing a life-threatening infection. As such, renal and bladder sonography is important in the evaluation of neonates with candiduria.Effects of Continence in Children Essay

There is no consensus regarding the treatment of pediatric candiduria. Measures include stopping antibiotics if possible, removing or changing indwelling catheters, and antifungal therapy. Commonly used antifungal agents include oral fluconazole and parenteral, intrarenal, or intravesical amphotericin B. In patients with obstruction or failure to improve with medical management, urgent percutaneous nephrostomy tube placement to drain the kidney may be needed. Additional measures include amphotericin B irrigation of the nephrostomy tube, or even nephrectomy in severe cases.Effects of Continence in Children Essay

Viral cystitis represents another form of non-bacterial UTI affecting children. Adenovirus types 11 and 21, influenza A, polyomavirus BK, and herpes simplex viruses can cause irritative voiding symptoms, hemorrhagic cystitis and even vesicoureteral reflux or urinary retention. In non-immunized or immunosuppressed children, herpes zoster cystitis presents similarly. Fortunately, these forms of cystitis are self-limited. Immunosuppressed children undergoing kidney or bone marrow transplantation, or those receiving chemotherapy are especially susceptible to viral cystitis, including those caused by cytomegalovirus and adenoviruses 7, 21, and 35. Antivirals such as ribavirin and vidarabine may be helpful when viral cystitis is diagnosed.

Acute sequelae of pediatric bacterial UTI include the spread of infection outside the urinary tract, resulting in epididymitis or orchitis in boys, and sepsis. The most common serious sequelae of pediatric UTI is that due to pyelonephritis. Chronic pyelonephritis results from persistent infection after acute pyelonephritis and can result in pyonephrosis, xanthogranulomatous pyelonephritis (XGP), and renal parenchymal scarring with hypertension and renal insufficiency. The accumulation of purulent debris in the renal pelvis and urinary collecting system, known as pyonephrosis, occurs when pyelonephritis is accompanied by urinary tract obstruction. Pyonephrosis requires appropriate antimicrobial therapy and prompt drainage of the urinary tract with percutaneous nephrostomy tube placement or retrograde catheterization.Effects of Continence in Children Essay

XGP is a rare clinical entity in children affecting < 1% of cases with renal inflammation. Like pyonephrosis, it develops in the setting of chronic obstruction and infection. The most common pathogens causing XGP are Proteus and E. coli. XGP is usually unilateral and may extend diffusely throughout the affected kidney and even into the retroperitoneum and cause fibrosis of the great vessels. Radiographically, it can be mistaken for childhood renal tumors. Histologically, the XGP kidney shows evidence of pyonephrosis and xanthoma cells, which are foamy, lipid-laden macrophages. Treatment often involves nephrectomy.

Pyelonephritogenic scarring with renal parenchymal damage occurs more commonly in children than adults for unclear reasons. Renal scarring from pyelonephritis appears to be influenced by at least 5 factors: age, treatment, host immunity, intrarenal reflux, and urinary tract pressures. Future hypertension occurs in at least 10-20% of children with pyelonephritogenic scarring. Hypertension in this setting occurs independent of the degree of renal scarring.Effects of Continence in Children Essay

Children with recurrent pyelonephritis may also develop progressive renal insufficiency without a UTI symptoms. End-stage renal disease from reflux nephropathy (pyelonephritogenic scarring in the setting of vesicoureteral reflux, discussed below) accounts for 7-17% of end-stage renal disease worldwide, and 2% of cases in the U.S. Effects of Continence in Children Essay

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