Fiona Le Ber, Queen’s Nurse,Education & Development Coordinator, Family Nursing & Home Care, Jersey, introduces the event.

Fiona Le Ber, Queen’s Nurse, Education & Development Coordinator, Family Nursing & Home Care, Jersey, began the day with the Chair’s opening remarks. She was thrilled to welcome the keynote speaker, Jacqueline Emkes, patient advocate who shared her personal experiences and her national involvement in raising awareness of bladder problems, to improve service provision.

The morning lectures continued with Anna Hancock, Clinical Nurse Specialist for Continence Care at Coventry and Warwickshire Partnership NHS Trust. Anna delivered an engaging and interactive session, testing delegates knowledge on essentials of continence assessment.

Janice Reid, Lecturer in Nursing, School of Nursing, University of Ulster, delivered
an interesting lecture on initial management of continence, including continence disorders and individualised management plans and discussion of first line conservative therapies for common problems affecting both bladder and bowel in adults. Janice explored the need for setting realistic treatment goals within the framework of shared decision making and person-centered care.

The morning session concluded with an insightful update on resources to support continence care, delivered by Nikki Cotterill, Professor of Nursing in Continence Care at the University of the West of England and North Bristol NHS Trust. Nikki highlighted the importance of remembering that each encounter is an opportunity to promote continence, that individuals do not need to be continence experts but need to have the confidence and language to initiate discussions. Nikki explained that enabling disclosure is a priority and signposted to some resources with suggestions about what to do next including:

• The CONfidence app which enables people with bladder or bowel issues to gain information about the causes of bladder and bowel issues, self-help, treatments, products, practical tips and support services. There are additional sections for carers, partners and young people. (www.confidenceapp.uk)

• Continence Product Advisor containment product selection for adults with urinary and/or faecal incontinence. It includes practical considerations for males and females, providing impartial and evidence-based information. (www.continenceproductadvisor.org)

• The bladder & bowel service map highlights the location of adult and children’s services in England by region. The contact and website details for all services are listed. (www.bladderandbowelservicesmap.com)

From the voluntary sector, Nikki highlighted the charities:

• Bladder & Bowel UK (www.bbuk.org.uk)

• Bladder Health UK (www.bladderhealthuk.org)

• ERIC – Children’s bowel and bladder charity (www.eric.org.uk)

Afternoon workshops were delivered and facilitated by committee members with delegates being able to attend all the sessions in small groups.

Karen Irwin, Bladder & Bowel UK, running the puzzle by products workshops.

Karen Irwin, Service Manager / Specialist Nurse, Bladder & Bowel UK, led the ‘Puzzle by Products’ workshops where delegates discussed how introduction of containment products and other resources may help improve quality of life for those experiencing bladder and bowel health issues. They also considered potential challenges faced in selecting appropriate products, including a wide range of toileting aids and equipment that has been designed to enhance incontinence management or assist with toileting. Jenny McCarthy, Clinical Nurse Specialist for the Emerald Nursing Team at B. Braun led a workshop on ‘Demystifying Laxatives’ and Victoria Coghlan, Nurse Consultant Bladder and Bowel, Aneurin Bevan University Health Board led the ‘Catheter Troubleshooting’ workshop

The event received very positive feedback. Delegates were directed to the numerous resources available on the RCN Bladder and Bowel Forum website, including free webinars, informational content, and support materials, accessible here.

The forum also has a closed Facebook page that members can join.

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Background

Functional bowel disorders (FBDs) are a group of medical conditions that affect the normal functioning of the gastrointestinal (GI) tract without any apparent structural or biochemical abnormalities. These disorders are common, affecting over 25% of UK adults¹. The term “functional” means that the disorder is primarily related to how the GI tract functions rather than any specific physical damage or disease.

Some common functional bowel disorders include:

• Irritable Bowel Syndrome (IBS) – IBS causes abdominal pain or discomfort, along with changes in bowel habits, such as diarrhoea (IBS-D) constipation (IBS-C) or alternating between the two (mixed IBS).
• Functional Constipation – infrequent bowel movements, difficulty passing stools, and a feeling of incomplete emptying.
• Functional Diarrhoea – frequent loose or watery stools without any identifiable cause.
• Evacuatory Dysfunction – difficulty in passing stools, often associated with excessive straining and a feeling of incomplete evacuation.
• Faecal incontinence – the accidental passage of stool from the rectum.

In clinical practice, symptom overlap is common among patients. They frequently speak of the considerable burden these conditions have on various aspects of their lives, including relationships, overall health, and ability to work. These insights led to the development of the PERSPECTIVE study.

The PERSPECTIVE study has explored the impact of the aforementioned FBDs on patient’s lifestyle, including their real-world experience of using transanal irrigation (TAI) to manage these symptoms. This study differs from previous studies as it has explored a wider range of FBDs. This article will discuss the results regarding TAI usage.

Method

A total of 4,794 individuals were invited to participate in the study from two existing cohorts of people, sourced from two existing databases:

1.  ContactME-IBS – a dedicated national registry (NHS owned) for individuals who self-identify as having any type of IBS. People sign up to receive information about research opportunities, without any obligation to participate. This provided access to over 4,000 individuals from both primary and secondary care.
2. Durham Transanal Irrigation database, which had over 200 TAI users, all seen in secondary care.

Data from 933 respondents were captured through a single online questionnaire. Among them, 183 (20%) had experience of using TAI, and 110 (60%) continue to use it.

Results

In the study, females were primarily irrigating for constipation-related symptoms (43, 44%), while males used it predominantly for diarrhoea or mixed-type symptoms (9, 82%).

Respondents often faced delays in starting TAI, with 48 (44%) reporting symptoms for 10 or more years before beginning treatment. This delay could be attributed to various factors such as the time it takes to access specialist services. There is a need to increase awareness around bowel dysfunction and the benefits of treatments to address this issue.

Respondents were asked to rate how effective TAI was for them at 3, 6, and 12 months using a scale of 0 (no benefit) to 10 (excellent). At 3 and 6 months there was a positive correlation, meaning that if TAI was effective at 3 months, it was likely to still be relieving symptoms at 6 months. In fact, the trend for effectiveness continued up to 12 months. So, TAI being effective at 3 months is a good indicator of longer-term effectiveness.

In fact, the findings suggest long -term effectiveness way beyond the 12- month period explored. The majority of respondents (58, 53%) had been irrigating for 3 or more years and 33 (30%) had been irrigating for even longer (5-10 years). Since TAI requires time and commitment, it is reasonable to conclude that patients will continue to use it if they are finding it beneficial in relieving their bowel symptoms. Hence, long -term use suggests long-term effectiveness.

TAI is an effective treatment for all types of FBDs. The 60% success rate in PERSPECTIVE is similar to that of other studies^3,4.

Interestingly, when we examined the data around those who continued irrigating and those who had stopped, we discovered that respondents with diarrhoea-related symptoms (IBS-D, functional diarrhoea, or faecal incontinence) were the highest proportion which continued using TAI (74%, 26). Among this group, a considerable percentage (77%) also reported faecal incontinence. Perhaps the burden of faecal incontinence contributes to the continued use of irrigation as a treatment option.

Implications for practice

The PERSPECTIVE results have significant implications for both patients and healthcare professionals:

• Patients with a wide range of FBDs can benefit from irrigation.
• Patients with IBS-D, diarrhoea, and faecal incontinence in particular, find irrigation beneficial.
• Reassurance for patients – that the therapeutic effects of TAI will not diminish over time, as observed with other treatments such as laxatives.
• Effective TAI can create clinical capacity – longer term efficacy means that healthcare professionals can confidently discharge patients back to GP care. Thereby freeing up valuable clinical resources and capacity, enabling more patients to be treated.
• Encourage patients to persevere with irrigation for up to 3 months, as per the follow up regime proposed by Emmanuel et al². After which time, if it’s beneficial continue, if not then stop.
• If irrigation does not give satisfactory results after the initial 3 month-period, refer back to the multidisciplinary team for further advice, aligning with the follow-up recommendations proposed by Emmanuel et al².
• These approaches streamline what is currently a convoluted journey for patients to access specialist treatment.

This post was written by Michelle Henderson, Clinical Education Manager, MacGregor Healthcare.

The post Insights from the PERSPECTIVE* Study: Using Transanal Irrigation for Functional Bowel Disorders – What are the Implications for Practice? appeared first on Bladder & Bowel UK.

Because urinary incontinence (UI) is rarely talked about openly, there is a lot of misunderstanding around the issue. Therefore, whether someone is dealing with short term, long term or permanent incontinence, they might experience difficulties socially and psychologically. This article discusses the experience of stigma amongst people suffering from urinary incontinence, to create greater understanding and empathy around this common medical condition.

Stigma and UI: the basics

Definition of stigma: feelings of disapproval that people have about particular illnesses or ways of behaving.

Men, women and children can experience urinary incontinence and associated stigmas. Causes in adults can include stroke, some cancers, neurological conditions, dementia, obesity, presence of lower urinary tract symptoms and decreased mobility. Women are generally reported as having a higher prevalence of urinary incontinence, due to different anatomies and causes of urinary incontinence, and additional causes can include childbirth and menopause. It is also common for men to experience urinary incontinence following a prostatectomy, with rates increasing from 5% to 60% prevalence among this group.

Stigmatisation is a process of exclusion. When an issue, such as incontinence, is stigmatised, this leads to two groups existing: those who do have the trait, and those who don’t. Stigma can have a big impact on a person’s self-identity, and it is now well understood to have a serious negative effect on physical and mental health.

Why might UI be stigmatised more than other conditions?

We are brought up to understand from an early age that passing urine and faeces (wee and poo) should be done in private, and in a tidy way. Incontinence can rupture this social norm. Many people affected by urinary incontinence fear associations of uncleanliness, sexual impotence, or being ‘an outsider’ socially. They may fear being perceived – or may perceive themselves – as weak, dependent, or doddery. They may be embarrassed or ashamed.

Research has shown that the stigma of urinary symptoms is tied to how far the problem is perceptible – whether visually (such as marks on clothing or visible products), due to odour (such as the smell of urine in the home or on somebody themselves), or behaviourally (such as avoiding activities, or needing to make frequent trips to the bathroom). If someone has an ‘accident’ or is not able to contain their incontinence, they may be distraught and worried about what others might be thinking. This is an understandable response, but it’s important to bear in mind that urinary incontinence is a medial condition that should be treated with empathy.

The stigma of incontinence is a serious issue. Stigma creates stress, and then worsens people’s ability to deal with the stressful situation. It can lead people to stop living their normal lives, leaving the house, and going about their day-to-day activities, causing them to become isolated and withdrawn. This might mean they are less active, in turn causing greater physical and mental health issues. It can also remove people from their social support networks, cutting them off from people who can help.

Crucially, the shame felt as a result of bladder and bowel health problems, including urinary incontinence, can be a barrier to treatment. People might deny or conceal their condition, and put off seeing a doctor, especially if the matter is concealed from even close family and friends. This delays timely treatment which might lead to a cure. Remember, there are lots of management and treatment options out there. Without medical advice and help, a potentially resolvable problem can stay untreated.

Stigma has a strong link to mental health concerns, such as reduced self-esteem, increased anxiety and depression, and can affect relationships, employment and overall life stability. Many people with incontinence symptoms report feelings of powerlessness, and feel a lack of agency over their own body. If you are struggling with your mental health as a result of urinary incontinence, it is important to speak to your doctor, or reach out to a mental health organisation, such as a local NHS service, or Mind.

“Crucially, the shame felt as a result of bladder and bowel health problems, including urinary incontinence, can be a barrier to treatment.”

What can be done to reduce people’s exposure to stigma?

New treatment and management options have been developed to provide a broader range of choices to people. These can lead to rehabilitation or better management of incontinence, meaning reduced exposure to stigma, and improved quality of life. Urinary incontinence is common but every patient’s position is unique. The good news is that product innovation continues, leading to a wider range of available products to help people best manage their particular condition.

Just as stigma can cause an obstacle to treatment and management, effective treatment and management can help people regain feelings of agency, and get their self-identity back. This is why seeking help from medical professionals and experts in incontinence products is important.

Ultimately, people dealing with continence issues do not need to suffer in silence. All health concerns deserve to be treated with respect, and the right to comfort and dignity are human rights.  There are a greater number people who are affected by incontinence than you would think, and there are organisations and professionals who can provide support and guidance for improved quality of life.

This article is part of the Education Spotlight on Urinary Incontinence, supported by iMedicare. You can also read more about constipation in our information library here.

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INTRODUCTION

A 42-year-old woman (Lucy, pseudonym) presented to a pelvic floor unit with symptoms of tenesmus, a feeling of incomplete evacuation and a sensation of pressure in her vagina. These symptoms have been present since the birth of her second child. She has noticed them becoming more problematic, particularly in the past 2 years.

Lucy lives with her partner and two young children aged 9 and 11 years. She is a primary school teacher and works part-time. On ‘bad’ days she can visit the toilet multiple times, which is especially difficult to manage if she is at work, as she is unable to leave the classroom during lesson time.

ASSESSMENT

Assessment is a fundamental part of the treatment process for a patient and is considered the first step of individualised nursing care. The information that is collated from the assessment is significant to the development of a plan of action that augments health outcomes relevant to the patient.

Lucy’s assessment began with her GP, although she found it embarrassing discussing her bowel symptoms. However, in recent weeks she suffered episodes of post defaecation seepage and experienced leakage during sexual intercourse, which prompted her to visit her GP for advice. This led to a referral to the pelvic floor services at her local hospital who assessed holistically taking into account physical, psychological and social wellbeing.  Her assessment revealed the following:

Bowel symptoms

• 2 bowel movements per week, type 2-3 stool (Bristol stool chart). For as long as she can remember she has been ‘prone to constipation’ and is used to moving her bowel infrequently.
• A feeling of incomplete evacuation. She has read on the internet that she should avoid straining.
• Post defaecation seepage, which is unpredictable and left her feeling unclean, therefore location of toilets is important to know.
• Feels a pressure rectally/vaginally after having a bowel movement.

Medications

• Has tried a variety of laxatives, but experienced abdominal pain and their unpredictability of effect was very difficult to manage. In our clinical practice, it is noted that many patients prefer not to take laxatives for these reasons, despite the impact of symptoms on their quality of life. It is useful to identify constipation which occurs due to evacuation disorders as this does not respond well to laxative therapy¹.
• No other medications taken.

Diet

• 3 meals per day
• Tries to be as healthy as possible, inclusive of 5 portions of soluble fibre each day.
• However, eating more fibre, particularly insoluble fibre, leads to bloating and bowel frequency doesn’t improve. Insoluble fibres can cause increased bloating and may not improve slow transit constipation². On the other hand, it has been demonstrated that diets with soluble fibre can be associated with the improvement of the symptoms in chronic constipation without causing increased bloating³. Although Lucy has not been diagnosed with slow transit, her infrequent bowel movements suggest otherwise.

Digital rectal examination

• No pelvic floor descent, good strength and tone of the pelvic floor muscles, palpation of the anterior rectal wall suggested a rectocele, nil other to note.
• Balloon expulsion was carried out with an Ashley balloon catheter (See figure 1) and demonstrated a slight incoordination of pelvic floor and anal sphincter muscles but no straining.

Figure 1

Investigations

• A defaecating proctogram confirmed a moderate rectocele with trapping of stool. No perineal descent and nil other to note.

Psychological & Social wellbeing

• Faecal leakage has occurred during sexual intercourse, which has left her mortified and avoiding any intimacy with her partner. When a person experiences a traumatic event, their brain may process the event in a way that causes them to feel stuck in a state of hypervigilance or fear, even after the threat has passed. Trauma can also interfere with a person’s ability to form healthy attachments and relationships with others, which can further exacerbate feelings of anxiety and isolation. Lucy has developed a fear of faecal incontinence occurring again, creating anxiety around her relationship with her partner.
• Toilet-centred behaviour, avoids unfamiliar places and finds socialising difficult.

To summarise, Lucy has a moderate sized rectocele and feasibly slow transit constipation, as she is only having 2 bowel movements per week. Her most bothersome symptom is stool trapping in the rectocele, which has led to incontinence.

For further information on rectoceles please visit:

https://www.rcog.org.uk/for-the-public/browse-all-patient-information-leaflets/pelvic-organ-prolapse-patient-information-leaflet/

TREATMENT PLAN

Setting goals

• The treatment plan should be one of shared decision making, taking into account patient preferences⁴. This encourages active involvement and commitment to the proposed interventions⁵.

Lucy’s assessment identified her treatment goal using the MYMOP questionnaire (https://www.meaningfulmeasures.co.uk/). This is a problem specific individualised measure. It is quick and simple to use and captures which symptoms are most important to the patient and which activities of daily living they affect. Her goal was to improve rectal evacuation so that the number of toilet visits were reduced, and the risk of incontinence eliminated.

Treatment options for rectocele depend on the severity of symptoms. NICE (2022)⁶ recommend the following strategies:

Lifestyle modifications

• Lifestyle modifications such as weight loss and smoking cessation are frequently recommended as first line management strategies for bowel dysfunction, including rectocele⁶. Obesity and coughing can strain already weakened pelvic floor muscles. However, this is expert opinion since evidence for these is lacking⁴.

Since Lucy neither smokes nor was overweight these were not discussed.

Preventing or treating constipation

• Lucy was advised to slowly increase the amount of soluble fibre in her diet, to prevent bloating. She did not wish to pursue laxatives due to the unpredictable effects.

Oestrogen therapy

• Vaginal oestrogen should be considered for women with pelvic organ prolapse and signs of vaginal atrophy.

Lucy was having regular periods. There were no signs of vaginal atrophy.

Pelvic floor muscle training

• A tailored programme of pelvic floor muscle training has been shown to be effective for relieving symptoms of prolapse by strengthening the muscles and tissues that support the rectum and vagina, alleviating pressure and discomfort⁷.

Lucy had good strength and tone of her pelvic floor and was given a personalised programme to follow.

Rectocele support e.g., vaginal pessaries, splinting, digitation

• Physical support of the rectocele can aid evacuation.

Lucy was taught defaecation dynamics to optimise positioning on the toilet. However, she did not wish to digitate and was embarrassed to continue splinting, stating she wanted ‘a solution for her problems’.

Due to the significant impact on her day-to-day life, a multi-modal approach was applied where Lucy would carry out the tailored pelvic floor exercises and employ rectal irrigation at the same time to enable more complete evacuation, relieving symptoms of post-defaecation seepage, tenesmus and sensation of pressure. Igualada-Martinez et al (2022)⁸ recommends early intervention of rectal irrigation (as an alternative to suppositories), before pelvic floor muscle training, potentially giving symptom relief whilst strengthening these muscles.

RECTAL IRRIGATION

Initiation

Rectal irrigation involves instilling warm tap water into the rectum via a cone or catheter. When this is removed, the water is expelled along with the contents of the rectum and descending colon. The degree of evacuation will depend on several factors including the amount of water that is used.

The wide range of equipment available can be confusing for health care professionals (HCPs). The decision guide is a consensus document based on current evidence and best practice. It guides the HCP through the process of starting a patient on rectal irrigation, including choosing high or low volume irrigation, catheter or cone, aspects to include during teaching and when to follow up.

The decision guide (step 2) recommends low volume irrigation for rectocele and high volume for constipation. In our clinical experience, presentation of bowel conditions as described, the choice of product would lean to high volume, as this will address all symptoms, especially when using the Qufora IrriSedo Flow system, therefore addressing both the constipation with the volume of water and the rectocele with a cone that has a shower effect. Also, bearing in mind that Lucy had good dexterity and no issues with sitting balance therefore a cone system is deemed appropriate.

However, low volume was initiated for several reasons. Lucy’s most bothersome symptom was difficult evacuation (low volume recommended) with symptoms of tenesmus and stool trapping leading to faecal incontinence. She also had a very busy lifestyle so was concerned how irrigation would fit into her routine. For these reasons low volume was chosen i.e. Qufora IrriSedo MiniGo, which looked quick, easy and discreet to use.

Follow up

2-week telephone review

• Procedure took 10 minutes in the morning after breakfast
• Irrigated 10 out of 14 days
• 4 great results, more comfortable and less toilet visits
• 6 days of continued previous symptoms
• Plan – to continue with low volume irrigation, as symptoms may improve

4-week telephone review

• Insufficient relief
• Tenesmus and frequent toilet visits persisted, there had been a few instances of post-defaecation seepage and she was still avoiding intimacy with her partner.
• Since adjusting to a rectal irrigation routine Lucy was aware that high volume would be the next step
• Transitioning to another cone-based product within the same range i.e. Qufora IrriSedo Flow, made teaching high volume straightforward. Lucy was already familiar with attaching the cone (which had the same lubricant, so she knew it was comfortable to insert and remove), the versatile water bag was convenient to use standing on the floor in her bathroom.
• To save another visit to clinic, a starter kit was delivered to her home, and this was taught virtually over a web call.
• Qufora IrriSedo Flow has been evaluated by HCPs as easy to teach, easy to learn and easy to use. This was reflected on the web call.

OUTCOMES

On speaking to Lucy at her 8-week review, it was evident from the tone of her voice that her confidence and self-esteem had improved. She was irrigating most days, using 500-600mls of water, and having very good results, passing dark brown water.  She felt that evacuation was complete, tenesmus and the sensation of pressure in her vagina had both disappeared. Episodes of post-defaecation seepage had stopped. She was happier and had been out shopping and for lunch with friends. She was looking forward to a date night with her partner.

CONCLUSION

This case study demonstrates the importance of identifying goals that matter to the patient. Holistic assessment identified that it was appropriate to start irrigation sooner in the treatment pathway, with a multi-modal approach. Transitioning from low to high volume can be straightforward, leading to successful irrigation and the best possible outcomes for the patient.

REFERENCES

1. Bharucha AE, Pemberton JH, Locke GR 3rd. American Gastroenterological Association technical review on constipation. Gastroenterology. 2013 Jan;144(1):218-38. doi: 10.1053/j.gastro.2012.10.028. PMID: 23261065; PMCID: PMC3531555

• Basilisco G, Coletta M. (2013) Chronic constipation: a critical review. Dig Liver Dis 2013; 45:886–93

• Suares NC, Ford AC. (2011) Prevalence of, and risk factors for, chronic idiopathic constipation in the community: systematic review and meta-analysis. Am J Gastroenterol 2011; 106:1582–91

• Assmann SL, Keszthelyi D, Kleijnen J et al (2022) Guideline for the diagnosis and treatment of Faecal Incontinence-A UEG/ESCP/ESNM/ESPCG collaboration. United European Gastroenterol J. 2022 Apr;10(3):251-286. doi: 10.1002/ueg2.12213. Epub 2022 Mar 18. Erratum in: United European Gastroenterol J. 2022 Jul;10(6):606-607. PMID: 35303758; PMCID: PMC9004250

• Booth J, Bliss D. Consensus statement on bladder training and bowel training.

Neuro-urology and Urodynamics. 2020;1–21.36

• NICE (2022) Urinary incontinence and pelvic organ prolapse in women: management (NG123)

• Hagen S, Stark D, Glazener C et al (2014) Individualised pelvic floor muscle training in women with pelvic organ prolapse (POPPY): a multicentre randomised controlled trial. The Lancet vol 383,9919 p796-806

• Igualada-Martinez P et al (2022): Physiotherapy Management of Anorectal Dysfunction. Seminars in Colon & Rectal Surgery (2022), doi: https://doi.org/10.1016/j.scrs.2022.100936

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Shackley et al (2017) writing for the British Medical Journal states that the use of urinary catheters is one of the highest treatment options within our healthcare system, with 1 in 5 patients in hospital and 1 in 14 in the community setting being catheterised. The risks of indwelling catheters are well documented and include catheter-associated urinary tract infections (CAUTIs), bacteraemia and increased and urosepsis.

In 2015 the National Institute for Health and Care Excellence (NICE) acknowledged Intermittent selfcatheterisation (ISC) as the gold standard in continence care and this is now the preferred method of bladder management. The reason for this is that not only does ISC put the user in control of their own bladder function and facilitate normal voiding, but it can also reduce the risk of infection and offers greater psychological and physical benefits to a traditional indwelling catheter. (Catheter Care, RCN Guidance, 2019)

What is Intermittent Self Catheterisation?

Intermittent self-catheterisation (ISC) is defined by Shah and Leach (1998, cited in Naish 2003), as ‘passing a catheter into the bladder to remove urine when the patient cannot pass urine normally’. The procedure may be repeated every few hours if necessary and is viewed as an alternative technique to an indwelling catheter as a means of managing urinary problems. ISC is an established intervention (Addison, 2001, cited in Naish 2003) and is recognised as a safe and effective procedure (Moore, 1995, cited in Naish 2003). For many, the thought of undertaking ISC can be daunting, there is for some the fear of undertaking something medical, for others a fear of pain or discomfort. For most patients undertaking ISC, it is an essential task in order to maintain bladder function.

Who can be taught ISC?

Any individual proven to have a significant residual volume of urine over a prolonged period would benefit from ISC. This is because retaining urine is a significant risk factor and cause of urinary tract infections. Patients who undertook ISC would need to have good cognitive function and suitable dexterity or the support of a carer or family member in order to have a successful outcome. It is also important to choose the correct type of catheter to meet their needs, therefore holistic assessment is essential.

Urinary Tract infections (UTIs)

Urinary tract infections are divided into upper or lower UTIs depending on which part of the urinary tract is affected. The urinary tract consists of the kidneys and the ureters, the bladder and the urethra.

Lower urinary tract infections are much more common than upper UTIs and include the bladder and urethra. Upper UTIs are potentially more serious as they can involve the kidneys. Whilst it might seem a bit daunting that you can get a UTI from using ISC, it is important to remember that the risk of getting a UTI is much higher if you don’t use intermittent self-catheterisation. In fact, one of the key reasons that ISC is often recommended is to reduce the chances of developing a urinary tract infection. However, that does not stop patients worry about them, A Coloplast survey in 2016 of ISC users in the community setting states that 45% of patients worry about getting UTI’s when they self-catheterise. And most expect to get a UTI at least 2-3 times a year which is demonstrated in this case study below.

Case presentation

Bob (pseudonym) is a 62-year-old man with a spinal cord injury. He is paralysed from the neck down and no longer has any natural bladder function. He uses a wheelchair during the day and cannot stand to pass urine. He has chosen to undertake ISC for the last year, instead of having an indwelling catheter, but has experienced several episodes of uro-sepsis and admission to hospital. His wife performs the ISC for him, 5 times a day into a jug.

When we met Bob, he was using a good standard catheter that was functionally adequate however he was keen to explore if there was anything we could suggest that might make his life easier, particularly for his wife, and also help reduce the number of hospital admissions in the future. Owing to recent research we were able to discuss how the friction force of catheters could effect urethral trauma and therefore potentially increase infection rates. By undertaking a detailed consultation and listening to Bob and his wife’s needs we were able to show him a couple of new catheters, one of which has a catheter bag attached and is known as a “set” catheter.

Bob has highlighted to us that he did not go out often – he had never catheterised away from the home, the experience of catheterising usually meant leakage of urine as his wife struggled to catheterise and hold a jug. We were able to show him how to use Speedicath Flex Set, a new catheter that had a bag attached – this bag would capture the urine as ISC is performed, negating the need to use the jug.

Additionally this catheter has a triple action coating technology applied to the catheter – this makes insertion smoother – less friction should mean less trauma to the urethra and therefore long term reduce the potential of urine infections that in the past have led to sepsis.

The detailed consultation also allowed time to explore hygiene aspects with ISC and as the catheter has a sleeve, explain how this reduces the likelihood of cross infection but also discuss with both Bob and his wife the importance of hand hygiene. Bob has been using the catheter for a while now and has not had any further admissions to hospital. Most importantly, Bob has found new freedom. Accompanied by his wife they have managed to get out and about a little. They no longer use a jug and rely on this system to support their needs.

What is Friction Force and Triple action coating?

Within the case study we referred to friction force. A catheter with insufficient hydration can cause friction and irritation to the urethra. On average, catheter users catheterise 5 times a day – which adds up to 1825 times a year, this is why it’s so important that every single insertion and withdrawal of the catheter is as smooth as possible to reduce discomfort and protect the urethra. (Stensballe J et al 2005). The coating on the Speedicath Flex Set catheter that was used in this case study has the triple action coating technology. To protect the mucosa from the risks of damage, complications,** and UTIs,*** it’s important to have a coating that stays bonded, stays smooth and stays hydrated.

All SpeediCath catheters come with a unique hydrophilic coating, featuring our Triple Action Coating
Technology. It consists of three strongly bonded elements, designed to protect the urethra in three ways: it stays bonded, stays smooth, and stays hydrated.

Stays bonded
SpeediCath’s unique hydrophilic coating stays bonded during insertion and
withdrawal due to a proprietary base-coat that is covalently bonded to the catheter
surface for an even coating without dry spots.

Stays smooth
SpeediCath’s unique hydrophilic coating stays smooth because the polymer top-coat
enables excellent water absorption for low friction, smooth insertion and reduced
discomfort compared to uncoated catheters.

Stays hydrated
SpeediCath’s unique hydrophilic coating stays hydrated with a special water-based
solution that swells the coating and makes it instantly ready to use.

Making life easier

It is cases like Bob’s that make us realise how important it is to choose the correct catheter when performing ISC. Using current data, such as friction force data, to help empower patient choice is highly important. ISC offers significant advantages to that of alternative bladder management solutions and when performed well and concordantly will reduce UTIs, improve quality of life and enable independence.

References
1)IC value proposition January 2016: Coloplast survey, CIC users in community setting n=2942 (PM-06287) – on file

1. Stensballe J, Looms D, Nielsen PN, et al. Hydrophilic-coated catheters for intermittent catheterisation reduce urethral micro trauma: a prospective,
   randomised, participant-blinded, crossover study of three different types of catheters. Sponsored by Coloplast. EurUrol 2005;48(6):978–83, n=49. **
   Urethral bleeding (hematuria) and strictures
   *** compared to uncoated catheters
   • Sharkey et al (2017) Variation in the prevalence of urinary catheters: a profile of National Health Service patients in England. Published in
   the British Medical Journal 2017; 7(6): e013842. Found online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5577876/#:~:text=Our%20results%20
   indicate%20that%20urinary,more%20prevalent%20in%20males%20overall. (accessed 13th January 2021)
   • Vahr S, Cobussen-Boekhorst H, Eikenboom J, Geng V, Holroyd S, Lester M et al (2013) ‘Evidence-based guidelines for best practice in urological health care. Catheterisation; urethral intermittent in adults; dilatation, urethral intermittent in adults’. European Association of Urology Nurses (EAUN).
   • Naish, W (2003) Intermittent self-catheterisation for managing urinary problems
   • Catheter Care (2019), RCN Guidance For Healthcare Professionals, Pg 33
   • https://www.nhsemployers.org/pay-pensions-and-reward/nhs-terms-and-conditions-of-service—agenda-for-change/pay-scales (accessed
   10th January 2021)

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At Convatec, ‘forever caring’ is our promise to give patients and healthcare providers the support they need as we bring to life our vision of pioneering trusted medical solutions to improve the lives we touch.

Existing complications of traditional coated hydrophilic Intermittent Catheters

Clean intermittent self-catheterisation (CISC), while straightforward for some, can be both difficult and painful for others.

• 40% of participants affirmed “I have pain (the catheterisation is painful)”.¹
• CISC can also cause trauma to the urethra and result in bleeding.²
• 31% of people using hydrophilic coated catheters had blood in their urine, potentially higher than in uncoated catheters.²

In a recent ‘Guide to intermittent catheterisation technology’ supplement published by the British Journal of Nursing, pharmaceutical science lecturers from Queen’s University Belfast stated:

“A significant problem, noted anecdotally and in the literature, is catheter-coating dry-out³.

Hydrophilic-coated catheters are normally provided in packaging containing a hydrating fluid or supplied with a hydrating pouch for use prior to insertion. Once fully hydrated, they remain wet and lubricious for a relatively short amount of time only (5–20 minutes). As hydration falls below 75%, the coating loses its lubricious properties and becomes adhesive, tending to stick to the urethral mucosa⁴. Correspondingly, the increased force and friction on catheter withdrawal has been reported to cause trauma⁵, microtrauma and urethrorrhagia⁶.

It has been reported that almost one third of patients using hydrophilic-coated catheters were found to have haematuria, while 40% reported pain associated with catheter use. Persistent urethral bleeding is common with ICs, occurring in 11–28% of users^6,7,8. Furthermore, the delicate epithelial lining of the urethra forms the first line of innate immune defence against pathogens, so any injury could increase the likelihood of urinary tract infection (UTI).

ICs have been associated with development of trauma-induced urinary strictures, known to increase a patient’s risk of developing a UTI^9,10.”

Innovative Catheter Technology

We have not seen any significant changes in catheter technology since the 1980s, when the first hydrophilic catheter was launched. Until now.

We would like to introduce you to FeelClean Technology, Convatec’s unique, patented catheter technology delivering a smooth, easy cathing experience with products that do not stick^10,11.

Our GentleCath Glide and new, compact GentleCath Air range of catheters incorporate this pioneering FeelClean Technology designed to make the task of CISC an easier and more comfortable experience.

90% of users rated GentleCath with FeelClean Technology better than their usual catheter for comfort during use.¹²

So what makes FeelClean Technology different? Unlike traditional coated hydrophilic catheters, we have integrated the water-loving, hydrophilic properties within the catheter material itself – so your patients can enjoy no sticking, reduced residue^10,11 and relief whenever they cath.

What do our customers think of GentleCath with FeelClean Technology catheters?

“The catheter is significantly better on removal. Pain is significantly reduced for patients who catheterise regularly.” Rachel Skews,Urology Nurse Practitioner, North Bristol NHS Trust

“I have tried several different catheters. With other catheters, the hydrophilic coating is sticky, and I found that when withdrawing those catheters, it left a residue in my urethra and I was getting UTIs.  When I discovered GentleCath catheters, I was so happy, I cried. I have been using GentleCath for 18 months now and my infections have significantly decreased.” Alison Hodgson, Ex Nurse & MS Patient, Wolverhampton

A seamless service for your patients with Amcare Group DAC

For over 30 years, the Amcare Group has provided support to people living with a variety of medical conditions. We pride ourselves on offering a first-class personalised delivery service.

As your prescription partner, we offer a reliable, convenient, and discreet service direct to your patient’s door.

Once you have prescribed GentleCath for your patients, register them with Amcare for an easy, seamless service. We will take care of everything and support your patients through the next steps of their journey with intermittent catheters.

Why choose us?

• We have a team of professionals available 8am-8pm Monday to Friday, and 9am-1pm on Saturday to answer your patients’ questions.
• We handle your patients’ prescription requests for them, so they don’t have to worry. We offer a no-fuss, personalised care plan and make sure we are delivering supplies on time, every time.
• If a user is unhappy with their catheter, our team of Product Specialist experts will offer advice or help you select alternative options from a huge variety of product choices.
• With the ‘Follow my Parcel’ app, our delivery partner DPD enables users to arrange the best possible discreet delivery experience.
• Amcare is currently rated 4.1 (Great) on Trustpilot by our customers.

Convatec. Healthcare is changing. So are we.

Find out more about GentleCath intermittent catheters, visit: www.gentlecath.com/uk

Find out more about Amcare Group, visit: www.amcaregroup.co.uk

© 2022 ConvaTec. /® are trademarks of the ConvaTec group of companies. AP-61414-GBR

References:

1. Roberson D, Newman DK, Ziemba JB, Wein A, Stambakio H, Hamilton RG, Callender L, Holderbaum L, King T, Jackson A, Tran T, Lin G, Smith AL. Results of the patient report of intermittent catheterisation experience (price) study. Neurourol Urodyn. 2021 Sep 13.Irwin NJ, McCoy CP, McCullough AR, Corbett DJ. Use of in vitro and haptic assessments in the characterisation of surface lubricity. J Engin Med. 2019;233(1):84–90.
2. Rognoni C, Tarricone R. Intermittent catheterisation with hydrophilic and non hydrophilic urinary catheters: systematic literature review and meta-analyses. BMC Urol. 2017 Jan 10;17(1):4.
3. Guldager PM, Fredskilde KW, Nalbandian MT. Intermittent urinary catheter. Google Patents; 2019.
4. Vaidyanathan S, Krishnan KR, Soni BM, Fraser MH. Unusual complications of intermittent self-catheterisation in spinal cord injury patients. Spinal Cord. 1996;34(12):745–7.
5. Humphreys O, Pickering M, O’Cearbhaill ED, Flanagan TC. A biomimetic urethral model to evaluate urinary catheter lubricity and epithelial micro-trauma. J Mech Behav Biomed Mater. 2020;108:103792.
6. Webb R, Lawson AL, Neal D. Clean intermittent self-catheterisation in 172 adults. Br J Urol. 1990;65(1):20–3.
7. Bakke A, Vollset SE, Høisæter PÅ, Irgens LM. Physical complications in patients treated with clean intermittent catheterization. Scand J Urol Nephrol. 1993;27(1):55–61
8. Santucci RA, Joyce GF Wise M. Male Urethral Stricture Disease. The Journal of Urology, Vol. 177, No. 5, 2007, pp. 1667-1674.
9. Krebs J, Wöllner J, Pannek J. Urethral strictures in men with neurogenic lower urinary tract dysfunction using intermittent catheterization for bladder evacuation. Spinal Cord. 2015;53(4):310–313.
10. WHRI6933 TA 1369 FeelClean Phase 1 Report.
11. WHRI7131 TA 1486 v2.
12. A Multi-Centre Clinical Investigation to Assess the Performance of GentleCath Glide Intermittent Catheters. Study U378 GentleCath Glide Final Report. July 2018. Data on File. ConvaTec Inc.

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Cutting out your baseplate can seem like a task. Making sure you haven’t left any gaps that expose your skin to output and creating a seal strong enough to protect from leakage can be stressful.

When you use a Convatec Mouldable Technology baseplate, you don’t have to worry about gaps and a secure seal. Let the patented technology in the baseplate take care of that.

But don’t just take our word for it. Keep reading to learn more about Glen Neilson’s stoma story and how Mouldable has helped him to live life on his own terms and carry on doing the things he loves most, like climbing mountains. Glen has had his ileostomy for 22 years due to Ulcerative Colitis, but has never let his stoma dictate what he can and can’t do.

“My stoma was my life-saver. I completely understand why not everyone shares this feeling. But that’s how I have come to think of my stoma. It saved my life – and completely transformed the way I live my life.

But it hasn’t always been that way. I woke up during surgery in intensive care staring down at it. That wasn’t the best introduction! And neither was catching MRSA in hospital and spending 8 long months recovering at home with a hole in my stomach.

My first stoma bag didn’t bring any joy either. It didn’t help that I had problems around my stoma because of my baseplate and creases – and the fact my bag felt more like a carrier bag! It actually fell off the first time I ever went swimming. It took me two years before I would ever visit a pool again.

It wasn’t until I took to Google and ended up stumbling across the Convatec Natura two-piece bag that things started clicking into place (and I’m not just talking about the baseplate!).

The new bag gave me confidence and the old me started coming back. I got into going to the gym again, walking, golf and wild swimming.

After using the 2-piece Convatec Natura for years, and although I was more than happy with it, I just thought I would see if any new products were available or if there was anything available I didn’t know about as I was training for Kilimanjaro at the time. I wanted something that may not need cutting or worrying about the size compared to the stoma so was even more comfortable while I hiked.

This is when I was introduced to Convatec Mouldable Technology, which honestly was life changing for me. It is just amazing and gives me the confidence to climb mountains do my daily job here in the UK as a firefighter without any worries whatsoever. I truly believe no other product available on the market can match the superiority of the mouldable system.

The best thing about Mouldable is that it’s so easy to apply and there’s no cutting required. You literally just roll the baseplate back with your thumbs, apply it and it then gently returns to its original shape to hug my stoma, giving me a nice snug fit.

Another great thing about Mouldable is that a layer of the baseplate can absorb liquid output, causing it to gently swell around my stoma for an even better fit. Perfect for when I’m climbing mountains or when out on a job as a firefighter!

I would recommend Mouldable to anyone, as it literally has been life changing for me.

Want to learn more? Find out what others had to say about Mouldable in the video below.

The post Love your stoma skin with Convatec Mouldable Technology™ appeared first on Bladder & Bowel UK.

As the cost of living crisis worsens, we hear that more and more people are unable to afford essential products to manage incontinence. Bladder and bowel continence problems are common. 1 in 10 adults in the UK are affected by faecal incontinence, and the issue is closely associated with advanced age, and it is estimated that 34% of women are living with urinary incontinence. Incontinence poverty is a growing issue where people can not afford to buy the products they need to manage the problem, which can lead to significantly lower quality of life for individuals and their families, as well as other physical and mental health problems.*

The initiative, devised and delivered by Bladder & Bowel UK and NRS Healthcare, is using networks of community pantries, ‘warm banks’, luncheon clubs and community centres to share information about the provision of free essential products. Packs of incontinence products can also be requested over the phone. The items will then be posted free of charge to the individual’s home. †

“It is all-too-common that people don’t have the products they need to stay hygienic and comfortable, and the rising living costs we have seen will only make this true for more people,” says Karen Irwin, Bladder & Bowel UK’s Service Manager and Specialist Nurse. “We know that not having the right products can stop people leaving the house, seriously affect mental health, and also cause a massive strain on relationships.

“Having access to the correct products is essential to manage incontinence, an issue which affects so many people across the UK.”

Matthew Stead, Managing Director at NRS Healthcare says: “As the UK’s leading online living aids retailer we are delighted to partner with Bladder & Bowel UK to raise the issue of incontinence poverty in the UK, As the cost of living crisis continues to bite, some of the most vulnerable in society are hit the hardest. That’s why we and our suppliers have donated over £150,000 worth of products to this extremely important cause. We encourage anybody affected with incontinence who is unable to afford suitable products to get in touch with us.”

Requests for products can be made by phoning NRS Complete Care Shop on 01772 675 048, while stocks last. For guidance on managing bladder and bowel conditions, visit www.bbuk.org.uk.

*Patrick DL, Martin ML, Bushnell DM, Yalcin I, Wagner TH, Buesching DP. Quality of life of women with urinary incontinence: further development of the incontinence quality of life instrument (I-QOL). Urology. 1999 Jan;53(1):71-6

† While stocks last. Maximum two orders per household.

Bladder & Bowel UK support bladder and bowel health for everyone, offering a confidential helpline offering advice from specialist nurses and product experts. Find essential information about preventing and managing bladder and bowel issues for adults, children and professionals at www.bbuk.org.uk. Media enquiries: marketing@bbuk.org.uk

NRS Healthcare was established in 1947 and has developed a strong reputation for innovation in services and products in the area of rehabilitation aids and equipment for the disabled and injured including those to assist in the rehabilitation of servicemen following WW2. NRS has since grown to become a market-leading and award-winning provider of products and services designed to support independent living and is a trusted supplier to the NHS, proudly serving over 10 million people with mobility equipment and disability aids.  It also sells a range of over 4,500 products directly to millions of consumers via online channels. A smaller division provides clinical services to public sector customers.  NRS Healthcare is headquartered in Leicestershire and operates 22 depots across the UK.

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It is thought that that less than 40% of people with urinary incontinence seek help for their condition from a GP or healthcare professional. This figure is even higher for those with faecal incontinence. It is estimated that 14 million men, women, young people and children of all ages are living with bladder problems and 6.5 million adults in the UK suffer with some form of bowel problem (NHS England Excellence in Continence Care 2018).

Bladder and bowel care is fundamental to all holistic nursing and other health professional’s care. It is everyone’s business to identify and provide initial help to those with continence issues. It is not just the remit of those who work and specialise in bladder and bowel services.

For many, bladder and bowels are seen as a taboo subject. This increases the difficulty for professionals, as well as for the public in initiating conversations and in finding the right language. Many professionals may worry about managing the outcome of the discussion, if the subject is broached due to limitations of their knowledge: what is the right information to provide, what are the next steps and where can their patient go for more help and support. These legitimate anxieties together with knowledge gaps may result in patients not being asked about their bowel and bladder health.

Bladder and bowel conditions have a huge impact on all areas of an individual’s life, from self-esteem and wellbeing to quality of life. However, it is important that healthcare professionals let patients know that the conditions that cause bladder and/or bowel issues can be managed, treated and sometimes completely cured with the right support, advice and interventions. Healthcare professionals should therefore encourage individuals to have the initial conversations and avoid self-management or putting up with continence issues. Informing people that that much can be done to treat and improve symptoms and signposting to relevant services is important.

Healthcare professionals are often placed in a privileged and trusted position, where they can take and make opportunities, to speak to people about their bladder and / or bowel, opening conversations or building on information shared about an individual’s continence needs. Making every contact with patients a health promotion opportunity provides key opportunities including, but not limited to pre- and post-natal care, routine health checks, smear or prostate screening.

Setting the scene

So how, as health professionals, do we confidently start that conversation?

• Try to remove the taboo by asking people about their bladder and bowel health
• Be confident when asking questions
• Consider what information is required and what questions should be asked
• Consider what to do with the information once shared
• Know what local services are available for those with bladder and bowel issues and how to access these

.  How do we broach the topic? 

• Do not routinely recommend pads or other disposable continence products. If someone discloses a continence issue – there are many treatments and other forms of management that can stop or lessen the problem.
• ‘Trigger’ conversations can include simply asking people “does your bladder or bowel ever cause you any problems?” Conversations can develop from this.
• Utilise tools which can accessed locally or freely downloaded from the Bladder & Bowel UK website. These are designed to support staff working in any care setting.
• Knowledge will boost confidence – seek out and access training, education and updates on bladder and bowel health and care. This may be provided locally within your place of work, or contact us as Bladder & Bowel UK for further advice on courses, symposiums and bespoke training (BBUK@disabledliving.co.uk).
• Find appropriate patient information that you can share. This includes information on the Bladder & Bowel UK website at and the Bladder & Bowel UK helpline.
• Familiarise yourself with local referral pathways for those patients need specialist treatment or management.
• Understand what is usual and what is not normal – for example, lumps and bumps where they should not be, unexplained bleeding or sudden changes in bladder or bowel habits.
• Choose the right language: terms such as “do you have any problems controlling your bladder” or “do you have any problems going to the toilet” might lead to open dialogue.

Only by understanding and addressing the barriers to open conversation about intimate issues can we remove the stigma surrounding bladder and bowel health and ensure patients get the timely support and treatment they need.

For more information and resources for professionals working with bladder and bowel issues, visit our professionals’ section here.

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Edited by Emma Cooper, Editor of Pf Magazine.

This blog post examines the causes and diagnosis of opioid-induced constipation (OIC) and addresses effective routes to management for an improved quality of life.

Opioids are extremely effective painkillers that work by binding to receptors in the brain and spinal cord to relieve pain. Opioid-induced constipation (OIC) is part of a group of symptoms, collectively named opioid-induced bowel dysfunction (OIBD), that affect patients taking opioids. Studies suggest that OIC affects between 41% and 57% of patients taking opioids for pain (Cobo et al, 2021), and up to 87% of patients with terminal cancer using opioids (Cobo et al, 2021; Ahmedzai and Boland, 2010). Treating OIC is, however, extremely challenging.

Causes and diagnosis of OIC

As well as being present in the brain and spinal cord, opioid receptors are found in the gut, which means that the opioids can bind to the μ-receptors in the enteric system. When they bind to these receptors, they interfere with the body’s ability to move waste material through the intestines (Poulsen et al, 2015). The opioids inhibit gastric emptying and peristalsis in the gastrointestinal tract, resulting in the delayed absorption of medication and in increased absorption of fluid. The lack of fluid in the intestine leads to hardening of stool and constipation (Coluzzi et al, 2021).

The Rome IV criteria define OIC as ‘new or worsening symptoms of constipation when initiating, changing or increasing opioid therapy’ (Rome Foundation 2016). The criteria also states that these symptoms must include two or more of the following in at least 25% of defecations: straining, lumpy or hard stools, sensation of incomplete evacuation, sensation of anorectal blockage, use of manual manoeuvres to facilitate defecation, and fewer than three spontaneous bowel movements per week. In practice, however, the criteria are underused (Coluzzi et al, 2021).

The impact of OIC

The condition frequently has a negative impact on patients’ quality of life, including their ability to perform daily activities and work productively. They may also experience an increase in depression and anxiety. Some patients reduce or discontinue opioid treatment, preferring to experience the pain rather than the debilitating effects of OIC (Argoff et al, 2020).

OIC also has an economic burden. There is limited information about the cost to the NHS, though we do know that in 2018-19, the estimated annual spend by NHS England on constipation was £168 million (Bowel Interest Group, 2020).

The problem with laxatives

In people with OIC, laxatives are an ineffective treatment, as are bowel regimens, dietary changes, and lifestyle modifications. This is because they do not target the underlying cause – the opioid binding to the μ-receptors in the gastro-intestinal tract (Kumar et al, 2014).

Laxatives can also have unpleasant side effects. In one study of 198 patients taking opioid analgesics for at least one month, 73% had used laxatives at some point. Of these, 75% reported side effects, including gas, bloating or fullness, and a sudden urge to defecate. Approximately half of patients said laxatives interfered with work and social activities, and one fifth needed an overnight hospital stay because of their pain condition and/or constipation. Neither did laxatives improve the symptoms of constipation, as assessed by the Bowel Function Index (Emmanuel et al, 2017).

Using PAMORAs to treat OIC

Peripheral-acting mu opioid receptor antagonists (PAMORAs) are drugs that act directly on the mechanism causing OIC, combining with μ-receptors to inhibit the action of opioids in the gastrointestinal tract. Because PAMORAs reduce the effect of opioids in the gut without affecting how opioids work in the brain and spine, they enable the gastrointestinal system to function normally while maintaining the pain relief functions of opioids.

Addressing the problem

Healthcare professionals are often poorly informed about OIC and continue to treat it with ineffective laxatives rather than PAMORAs. One Italian multidisciplinary panel noted that use of the Rome IV criteria, which propose that OIC should be defined as new or worsening constipation when initiating, changing or increasing opioid therapy, mean that the early diagnosis of faecal stasis may be missed, particularly in older patients and those with cancer, and especially if bedridden (De Giorgio et al, 2021).

The panel also observed that not all specialists agree on the signs and symptoms of OIC specified in the Rome IV criteria, and recommend instead developing a symptom-based definition of OIC that is easy to apply in everyday clinical practice, both in community care settings (e.g. primary care and nursing homes) and in hospitals.

They note that current guidelines ‘do not provide a clear recommendation as to the frequency with which OIC should be evaluated’, and that therefore ‘constipation should be evaluated on a continuous basis in all patients who take an opioid.’

The recommendations made by the panel include proper education about OIC, stating: ‘Physicians of all specialties who treat patients on a long-term opioid, nurses, caregivers, and patients should be instructed about the risks of OIC and strategies for its prevention or treatment.’ The panel also recommends limiting interventions that rely on lifestyle changes or dietary and hydration changes, and that patients should not be left to solve the problem of OIC on their own.

Conclusions

The lack of physician awareness both of the impact of OIC and the appropriate treatments means that patients, many of them already seriously ill, often suffer unnecessarily. It is possible, however, to relieve symptoms through the use of better diagnosis and treatment.

In short, clinicians need to take a more proactive approach in the management of OIC, using a standard, symptom-based definition of OIC; educating themselves about treatment options; asking the patient regularly about symptoms; and making sure that patients receive therapy that manages their pain appropriately while avoiding the debilitating consequences of OIC.

To find out more about the impact of OIC, keep an eye out for the Bowel Interest Group’s latest report, The Cost of Opioid-induced Constipation, which will be published this summer and sets out to educate primary and secondary healthcare professionals in the management of OIC.

References

Ahmedzai, S H, & Boland, J. Constipation in people prescribed opioids. BMJ clinical evidence. 2010; 2407.

Argoff C. E. (2020). Opioid-induced Constipation: A Review of Health-related Quality of Life, Patient Burden, Practical Clinical Considerations, and the Impact of Peripherally Acting μ-Opioid Receptor Antagonists. The Clinical journal of pain, 36(9), 716–722. https://doi.org/10.1097/AJP.0000000000000852

Bowel Interest Group (2020). Cost of constipation report. 2020. Available from: https://bowelinterestgroup.co.uk/resources/cost-of-constipation-report-2020/

Cobo Dols M, Beato Zambrano C, Cabezón-Gutiérrez L, et al. KYONAL study. BMJ Supportive & Palliative Care. 2021 https://doi: 10.1136/bmjspcare-2020-002816

Coluzzi F, Alvaro D, Caraceni AT, Gianni W, Marinangeli F, Massazza G, Pinto C, Varrassi G, Lugoboni F. Common Clinical Practice for Opioid-Induced Constipation: A Physician Survey. J Pain Res. 2021; 14, 2255-2264
https://doi.org/10.2147/JPR.S318564

De Giorgio R, Zucco FM, Chiarioni G, et al. Management of Opioid-Induced Constipation and Bowel Dysfunction: Expert Opinion of an Italian Multidisciplinary Panel. Adv Ther. 2021; 38(7):3589-3621. https://doi: 10.1007/s12325-021-01766-y.

Emmanuel A, Johnson M, McSkimming P, Dickerson S. Laxatives Do Not Improve Symptoms of Opioid-Induced Constipation: Results of a Patient Survey. Pain Med. 2017; 18(10):1932-1940. https://doi: 10.1093/pm/pnw240.

Kumar, L., Barker, C., Emmanuel, A. (2014). Opioid-Induced Constipation: Pathophysiology, Clinical Consequences, and Management, Gastroenterology Research and Practice. 2014. https://doi.org/10.1155/2014/141737

Poulsen, J L, Brock, C, Olesen, A E, Nilsson, M, & Drewes, A M. Evolving paradigms in the treatment of opioid-induced bowel dysfunction. Therapeutic Advances in Gastroenterology. 2015; 360–372. https://doi.org/10.1177/1756283X15589526

Rome Foundation. Appendix A: Rome IV Diagnostic Criteria for FGIDs. 2016. Available at: https://theromefoundation.org/rome-iv/rome-iv-criter

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