Bowels and Urine
In the run up to publication of my new book Carers and Caring; the One Stop Guide; how to care for older relatives and friends I am sharing an A to Z of some of the practical solutions learned from research and experience. If you think any problems have been missed you can email me and tell me, and I’ll make sure they are covered in the next edition and online on my website at www.juneandrews.net. B for Bowels is one of the more challenging posts. If writing about it respectfully is difficult, how much harder to deal with it at home when caring for an older person.
When caring for someone else, you end up being involved in topics you’ve never discussed in your whole life. Sometimes people don’t even have the same words for what is being discussed. Talking about urination and defecation, passing water and opening the bowels, peeing and pooing, is hard enough. Dealing with it when it goes wrong is another level of complexity altogether. Aside from the practicalities, you have to deal with the potential shame and embarrassment of the person you are caring for, and your own mixed feelings. If you can remain calm and understanding it helps, but this can be a challenge if the older person resists your attempts to assist. This is one of the issues that can tip the decision to get professional help and may precipitate the person having to move into a care setting.
Some people do manage, but it is understandable when they can’t. Incontinence is when a person is unable to go to the toilet in the right place at the right time. It is not inevitable in old age, but many conditions that are more common in older people make incontinence more likely. So, for example if a person has arthritis or mobility problems, they may have difficulty getting to the toilet on time. If repeated episodes of incontinence occur, you should ask for an assessment from the GP. They might make a referral to a hospital urology clinic, and they may ask for the continence nurse adviser to see the person. This is a registered nurse with extensive training who can assess the condition and develop a management plan to suit the needs of the person you are caring for. They might visit them at home or see them in the clinic. Don’t just assume incontinence is part of normal ageing.
What is causing the continence problem?
From a practical point of view, how you manage it depends on what is causing the continence problem. Sometimes there is medicine that can help. At other times it can really make a difference if you just remind the person to go to the toilet frequently. There may be a temporary problem, such as a urinary tract infection, which makes it hard for the person to hold their water. In that case the situation might resolve itself after the infection has been treated. You will get advice from the clinical staff, but it is always the case that drinking more water and staying hydrated is good for the person. Logically, it might seem that you avoid having leaks by not drinking very much, but the opposite is the case.
Dehydration can lead to bladder infection
Anyone who becomes dehydrated is more likely to get a bladder infection, and that leads to irritation that can cause a person to wet themselves. Everyone should keep their pee straw-coloured by taking lots of fluid. If it gets any darker you are not drinking enough or you have an infection. Often you can tell there is an infection because there is a distinctive smell, and the urine is dark and cloudy no matter how much you drink. Follow your nose. If a person’s underwear or the toilet are smelly, that’s a clue. This is true for yourself as well as the person you care for.
Nursing staff can give advice about plastic bed covers, waterproof garments, adapted swimwear, continence pads and other items that protect linen and furnishings. Skin care is very important. The skin surface can break down with prolonged contact just like the painful nappy rash that children can have. The skin must be kept clean and dry. To find out more about the products that can help with this, look at the independent website www.continenceproductadvisor.org
Toilet design can make a difference
The design of the toilet makes a difference. The seat may have to be raised to reach the correct height, and grab rails needed to steady the person and give them confidence to sit. If a person has the right shoes on and the floor coverings are appropriate, they can make their way to the toilet faster. If they have too many zips and fastenings, layers of tights and knickers and other clothing to get off they may not be able to get to the toilet in time. Sometimes just thinking about going to the toilet can make the need more urgent. If the toilet is too far away or on the wrong floor of the dwelling you may need to acquire a commode, which is a portable toilet.
There is more about ‘Equipment for household tasks’ in the book.
If all else fails, a man may be provided with a penile sheath. This rolls on to his penis like a condom but has a collecting tube and a bag to collect urine, so it can be regularly emptied down the toilet. Keeping it clean is important. It might only be worn at certain times, for example in bed at night, if getting to the loo in time is difficult. Another device which can be used by men or women is a urinary catheter, which is inserted inside the bladder by the nurse and stays there with the tube coming out of the urethra. A bag is attached which collects the urine for disposal later. Hygiene is vital with these devices because they make the person vulnerable to urinary tract infections. The nurse who inserts it should show you how to keep it clean.
Faecal incontinence
Dealing with faecal (poo) incontinence is another issue. Clinical staff can tell a lot about someone’s health from their poo. The shape, colour, consistency and form give evidence about what you have eaten and whether your gut is coping with it. Even floating stools (poo) tell you something. If the person does less than three bowel movements in a week, that is viewed as constipation. That’s all very interesting for me as a nurse, but from a carer’s point of view the most urgent thing is what you do if it ends up in the wrong place at the wrong time.
The first thing is to tidy up the problem and the second is to see if it can be prevented from happening again. Again, it is not an inevitable part of ageing. Culturally this is a very hard task, even if you have often already cheerfully done it for small children, or even a puppy.
Disposable gloves and wipes
It’s a good idea to have some disposable gloves which you throw away after cleaning up poo from the person, their linen, or from hard surfaces such as the bathroom floor or toilet seat. Reusable rubber gloves are OK if you wash and disinfect them after each use. If you don’t have gloves, wash your hands thoroughly with soap and water, but also wash your hands after you take off gloves. If the person has faeces on their skin use damp paper towels or kitchen roll or non-alcohol wet cleansing wipes to wipe off the poo and put those in a rubbish bag. Wash the person with warm water and a soft cloth. Only use soap if water doesn’t do it, and make sure it is mild. If their skin is already red or has a rash, be sure not to use any wipes with alcohol as that will be very sore. Rinse well and dry carefully. Pat, don’t rub. Then throw away the gloves, wipes etc. When wiping stool off linen or clothes, if you can pick off pieces of it with toilet paper you can flush that down the toilet. Otherwise wipe with paper towels which you put in the rubbish bag and wash the clothes in hot water, using household laundry detergent and adding laundry bleach to the cycle if you wish.
The same technique for hard surfaces cleans away solid material, and then you can use whatever bleaching agent or antibacterial spray is normal for that surface. For fabric surfaces like chairs or rugs, use the same technique to get the poo off then wash the area with laundry cleaner. Use a white cloth or paper towel and dab at the stain to remove it. A white cloth helps you see when you need to shift to a different bit of the cloth as it lifts the dirt. After it dries you can disinfect it with a suitable product spray, checking first that it will not discolour the rug or fabric. In care homes and other places where such accidents happen they buy chairs and floor coverings that look and feel like ordinary fabric, but which repel all fluids and dirt. You might consider this.
More information about bowels and urine
There is more information like this on the website of the Bladder and Bowel Community (www.bladderandbowel.org), which supports millions of people in the UK who are living with conditions that affect their bladder or bowel. For when you are out and about, through that site you can order a ‘Just Can’t Wait’ toilet card. This is credit card-sized and states that the holder has a medical condition which means they need to use a toilet quickly. This is extremely useful. Also they can tell you about the National Key Scheme that offers people who need it independent access to locked ‘accessible’ public toilets around the country.
There is much more about managing continence in Carers and Caring: The One-Stop Guide: How to care for older relatives and friends - with tips for managing finances and accessing the right support available from all good bookshops in May 2022
Three hints:
Always ask for a clinical assessment; treatment might cure it
Get help from the right people; there are solutions
For some people this is too much; that’s not your fault
