Continence care for patients with complex needs - Medicareplus International

Understanding incontinence

Incontinence is the unintentional leakage of urine, faeces, or both. Studies indicate that there are between three and seven million people with some degree of urinary incontinence in the UK1. Prevalence of both urinary and faecal incontinence increases with age2.

Types of urinary incontinence3

Stress incontinence Urine leaks out at times when your bladder is under pressure. For example, when you cough or laugh.


Stress incontinence is usually the result of the weakening of or damage to the muscles used to prevent urination, such as the pelvic floor muscles and the urethral sphincter.

Urge incontinence Urine leaks as you feel a sudden, intense urge to pass urine or soon afterwards.


Urge incontinence is usually the result of overactivity of the detrusor muscles, which control the bladder.

Overflow incontinence When you are unable to fully empty your bladder, which causes frequent leaking.


Overflow incontinence is often caused by an obstruction or blockage in your bladder, which prevents it from emptying fully.

Functional incontinence This type of incontinence occurs because of something else happening in your body or mind – be it musculoskeletal issues, neurological issues, or issues that affect our ability to think and communicate as we usually would, such as mental health or memory issues. These issues can result in realising the need for the toilet too late, being too slow at reaching the toilet, being unable to remove clothes with ease, or even ignoring one’s own need for the toilet4.



Mixed incontinence Occurs when symptoms of both stress and urgency types of incontinence are present. Often, symptoms of one type of incontinence may be more severe than the other5.
Total incontinence When your bladder cannot store any urine at all, which causes you to pass urine constantly or have frequent leaking. Total incontinence may be caused by a problem with the bladder from birth, a spinal injury, or a small, tunnel like hole that can form between the bladder and a nearby area (fistula).


Humans are not born continent; it is a skill we learn in childhood to recognise sensory urges and motor control6. People require several interrelated cognitive and physical skills to remain continent. This chain can be broken at any time with one or a mixture of elements:

  • Disease
  • Disability
  • Environmental events
  • Individual thoughts and beliefs7.

Incontinence in the older adult is associated with8:

  • reduced mobility
  • declining cognitive function
  • decreased bladder capacity, reduced sphincter and muscle tone
  • poor nutrition

Dementia and incontinence

Complexities can occur in toileting pathways for the person living with dementia. We must explore on an individual level what the causes of this, are and how to overcome difficulties associated with this. People are not incontinent because they have dementia, and there is not one reason they wet or soil themselves. As just one example, if a person with dementia no longer has any memory of the toilet training we received in childhood, the consequences can be life-altering.

 Potential causes of toileting difficulties3:

There are many, complex potential causes of toileting difficulties. In people with dementia, these may not be related to functional problems with the bladder but may have more complex causes such as:

  • Not reacting quickly enough to the sensation of needing to use the toilet.
  • Not getting to the toilet in time – for example, because of limited mobility.
  • Not being able to tell someone that they need to go to the toilet because of difficulty communicating.
  • Not understanding a prompt from someone to use the toilet.
  • Not being able to find, recognise or use the toilet. If someone becomes confused about their surroundings, they may pee in an inappropriate place (such as a wastepaper basket) because they have mistaken it for a toilet.
  • Not being able to, or forgetting how to, do things needed to use the toilet, such as undoing clothing.
  • Not letting others help with going to the toilet or refusing to use it could be due to embarrassment or not understanding an offer of help.
  • Not making any attempt to find the toilet could be due to depression or a lack of motivation or because the person is distracted.
  • Embarrassment after an accident, which the person unsuccessfully tries to manage. For example, they may try to hide wet or soiled clothes at the back of a drawer to deal with later and then forget they have put them there.

Prevention and management

Management of urinary or faecal incontinence in the older person begins with non-invasive behavioural interventions such as diet and fluid management or toileting techniques.

  • Help the person to identify where the toilet is. A sign on the door, including both words and a picture, may help.
  • Check the position of mirrors in the bathroom. The person with dementia may confuse their reflection for someone else already in the room and not go because they think the toilet is occupied.
  • Make it easier for the person to find their way to the toilet. Move any furniture that is in the way and leave open any doors that the person may find hard to open themselves.
  • Make sure the person has privacy in the toilet but check that they do not have difficulty managing locks.
  • Do not store equipment such as hoists in the bathroom which staff may need to access, affecting privacy.
  • Choose clothing that will be easier for the person to undo when using the toilet.
  • If the person is less mobile, handrails and a raised toilet seat may make it easier for them to use the .
  • Ensure the room is not cold; it is comfortable with dignity and privacy always maintained.
  • Other activities of daily living such as hair and teeth brushing should not be performed whilst a person is using the toilet.
  • If getting to the toilet becomes too difficult because of mobility problems, an aid such as a commode may be useful or a urinal bottle for men at night. Moving a person’s chair in the day room, for example closer to the toilet may be beneficial due to short term memory loss.


All these actions can help remove barriers and make it easier for the person to use the toilet more successfully.

Incontinence associated dermatitis (IAD)

Implementing a structured skin care regimen is essential to protect vulnerable skin in the person with chronic incontinence that may not achieve complete continence using available interventions or the person with acute onset incontinence associated with a systemic infection or other disorder such as a stroke9.

 Prevention and management of IAD is based on two principles of care:

  • Avoiding contact between urine or stool and the skin
  • Providing a structured skin care regimen that protects the skin from the damaging effects of urinary and or faecal incontinence.

A structured skin care regimen comprises three essential elements10:

  • cleansing the skin
  • application of a moisturiser
  • application of a skin protectant

Learn more on the prevention and management of IAD and access your toolkit for success from the links below that will take you to a selection of excellent resources – ready to access whenever you choose and to share with your team.

Download the MASD Toolkit here



  1. Hall, S., 2019. What Percentage of the Population are Affected by Incontinence? [online] Incontinence UK. Available at: <> [Accessed 27 April 2021].
  2. National Institute for Health and Care Excellence. CG97: Lower Urinary Tract Symptoms. NICE. 2010. London.
  3. Alzheimers Society (2012) Dementia UK. The full report. Alzheimers Society, London
  4. 2021. What is Functional Incontinence? | TENA UK. [online] Available at: <> [Accessed 27 April 2021].
  5. NAFC. 2021. Mixed Incontinence – NAFC. [online] Available at: <> [Accessed 27 April 2021].
  6. Bardsley A. Understanding incontinence in people with dementia. 2014.
  7. Kyle, G., 2012. An insight into continence management in patients with dementia. British Journal of Community Nursing, 17(3), pp.125-131.
  8. Sheng H, Wang Y. Urinary incontinence in dementia. 2008. Incont Pelvic Floor Dysfunct; 2(2): 63-66
  9. Gray,M. Incontinence Associated Dermatitis in the Elderly Patient: Assessment, Prevention and Management. Journal of ageing life care 2014;
  10. Beeckman D, Woodward S, Gray M. Incontinence-associated dermatitis: step-by-step prevention and treatment. British Journal of Community Nursing 2011; 16(8):382-9.