Clinical Guidelines for Acute Stroke Management - Living on the EDge

5.7 Incontinence
Section 5 Assessment and <strong>Management</strong> of the Consequences of <strong>Stroke</strong>
Dysfunction of the bladder and/or bowel is common
soon after stroke and may be caused by a combination
of stroke-related impairments (e.g. weakness, cognitive
or perceptual impairments). Incontinence is associated
with complications (e.g. depression) and prolonged
recovery and is a major factor <strong>for</strong> many patients and
their carers. 301
Urinary Incontinence
Several types of urinary incontinence occur after stroke
and hence assessment is important to identify distinct
aetiology to enable commencement of targeted
interventions. Methods of diagnostic assessment have
been described as a five step sequential process: 302
1. clinical history-taking, including history of incontinence
be<strong>for</strong>e the stroke, nature, duration and reported
severity of symptoms and exacerbating factors
including diet, fluid and medications;
2. validated scales that measure the severity of
symptoms and impact of symptoms on quality of life;
3. physical examination, including abdominal, perineal
(pelvic floor strength), rectal, neurological and
measurement of body mass index (BMI);
4. simple investigations, including urinalysis, midstream
specimen of urine (MSSU), measurement of post void
residual volume (PVRV), provocation stress test,
frequency–volume charts and pad tests;
5. advanced investigations, including urodynamics tests
such as cystometry, urethral pressure measurement,
pressure–flow studies, videourodynamics and
ambulatory monitoring.
<strong>Clinical</strong> history alone provided high sensitivity (92%) but
low specificity (56%) in determining a diagnosis of
incontinence when compared to urodynamic testing. 302
Post-void bladder scanning may also be useful to guide
assessment and management and has generally high
specificity (84-89%) and sensitivity (82-86%) compared
with urodynamics. 302 There<strong>for</strong>e all patients with stroke
should have at least a clinical history taken. If
incontinence is identified after obtaining the clinical history
then a physical examination and simple investigations
should be undertaken. Advanced investigations are not
justified routinely but may be considered later <strong>for</strong> those
whose incontinence has not resolved.
In general there is a lack of evidence <strong>for</strong> effective
interventions, particularly in the acute phase.
> One robust systematic review 301 noted two particular
studies that demonstrated benefits. One study found
a structured functional approach to assessment and
management, compared with a traditional
neurodevelopmental approach in early rehabilitation
increased the likelihood of being continent at
discharge. The other study demonstrated benefits of
care provided by a specialist continence nurse
compared with GP care once in the community. 301
This review found trials of physical, behavioural,
complementary and anticholinergic drug interventions
were inconclusive and more robust data are needed to
guide continence care after stroke. 301
> A second systematic review focused on behavioural
approaches to manage urinary incontinence. This
review found only modest evidence of the benefits <strong>for</strong>
urge suppression along with pelvic floor exercises,
however, more robust data are needed. 303
Faecal Incontinence
Faecal incontinence has been found to occur in 30% of
acute stroke patients however only 11% are incontinent
at 3-12 months post stroke. 304 Toilet access and
constipating drugs are two modifiable risk factors after
stroke. Constipation is also common post stroke as is
reported to be up to 66% in one community based
study. 304 The research base <strong>for</strong> management <strong>for</strong> faecal
incontinence and constipation is extremely limited and is
based on patients in rehabilitation and community
settings and further research in the acute phase is
needed although ef<strong>for</strong>ts should be made to effectively
manage any problems in the acute phase in order to
prevent further complications.
Evidence in this updated edition only rein<strong>for</strong>ced the
recommendations outlined in the <strong>Clinical</strong> <strong>Guidelines</strong> <strong>for</strong>
<strong>Stroke</strong> Rehabilitation and Recovery and readers are
directed to that document <strong>for</strong> more detail about
management of bladder and bowel dysfunction following
stroke. However, it is noted that extrapolated evidence
from stroke unit trials suggest bladder and bowel care,
especially avoidance of urinary catheters and treatment
<strong>for</strong> constipation, are important components of best
practice stroke care. 18
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