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NEW Delivery Of Stroke Rehabilitation to Optimize Functional Recovery
NEW Delivery Of Stroke Rehabilitation to Optimize Functional Recovery

10. Bladder and Bowel Function

Recommendations and/or Clinical Considerations
10.1 Bladder Function

10.1.1 Screening of Bladder Function 

  1. Individuals with stroke should be screened for urinary incontinence and retention [Strong recommendation; Moderate quality of evidence].

10.1.2 Assessment of Bladder Function

  1. Individuals with stroke experiencing persistent urinary incontinence should be assessed by trained personnel to determine the underlying cause and develop an individualized management plan [Strong recommendation; Moderate quality of evidence].
  2. The use of a bladder scanner should be considered to assess post-void residual as the preferred least-invasive method [Strong recommendation; Low quality of evidence]. 

Section 10.1 Clinical Considerations: 

  1. A structured assessment for urinary incontinence may include:
    1. Clinical history including location of stroke; past medical history of any previous incontinence or urinary symptoms and associated treatments; past gynecological or urological surgeries; history of vaginal birth; pre-stroke bladder habits and schedule; recent use of an indwelling catheter; current urinary symptoms and incontinence; daily liquid intakes.
    2. Physical examination including cognitive status, abdominal, pelvic and sacral examination.
    3. Review of medications for any potential contribution to the urinary symptoms of the individual.
    4. Use of a bladder voiding calendar, including details such as frequency, urgency, time of voiding or incontinence, difficulties starting urine, and volumes (voided or catheterized).
    5. Post-voiding residual volumes, measured with a portable ultrasound machine, to rule out incomplete voiding or retention.
    6. Urinalysis and urine culture and sensitivity if there is suspicion of a urinary tract infection. 
    7. In case of urinary retention, presence of concomitant constipation/fecaloma should be evaluated and appropriately treated.
    8. Referral to a urologist and/or urodynamic studies in selected cases, to further guide treatment.
  2. Individuals with stroke experiencing incontinence should be assessed for environmental and functional factors (e.g. limited mobility, limited communication) that may contribute to urinary incontinence.

10.1.3 Management of Bladder Function

  1. Routine use of indwelling urinary catheters in individuals with stroke is not recommended due to the risk of adverse outcomes, such as urinary tract infections [Strong recommendation; High quality of evidence]. 
    1. If used, indwelling urinary catheters should be assessed daily and removed as soon as possible [Strong recommendation; High quality of evidence]. 
    2. Peri care and infection prevention strategies should be implemented to minimize risk of infection [Strong recommendation; Moderate quality of evidence]. 
  2. Behavioral interventions, like timed voiding or a systematic voiding program, may be considered to reduce the number of urinary incontinence episodes and to improve quality of life [Strong recommendation; Moderate quality of evidence]. 
  3. Pelvic floor muscle training may be used to improve voiding frequency and urinary symptoms (including incontinence) [Strong recommendation; Moderate quality of evidence]. 
  4. Medication, such as anti-cholinergic or adrenergic agonists, should be considered for stress incontinence or urinary urgency, to improve urinary frequency and urgency, and decrease episodes of incontinence [Strong recommendation; Moderate quality of evidence].
  5. Transcutaneous electrical nerve stimulation (TENS) may be considered to reduce urinary incontinence after stroke [Strong recommendation; High quality of evidence]. 
10.2 Bowel Function

10.2.1 Screening of Bowel Function

  1. Individuals with stroke should be screened for fecal incontinence and constipation [Strong recommendation; Moderate quality of evidence].

10.2.2 Assessment of Bowel Function

  1. Individuals with stroke experiencing persistent constipation or bowel incontinence (for more than two weeks) should be assessed by trained personnel to determine the underlying cause and develop an individualized management plan [Strong recommendation; Moderate quality of evidence]. 

10.2.3 Management of Bowel Function

  1. An educational and behavioural program may be considered to reduce constipation/increase the frequency of bowel movements in individuals with stroke [Strong recommendation; Low quality of evidence].

Section 10.2.3 Clinical Considerations

  1. Dietary choices, judicious use of pharmaceutical treatments (e.g. suppositories, stool softeners), abdominal massage, and trans-anal irrigation may be considered as part of a bowel management program. 
  2. Establish bowel routines, including sitting on toilet at the same time daily; sitting upright with feet supported; with minimum of 10-15 min each time to help evacuate bowel.
Section 10 Additional Clinical Considerations
  1. Screening for bladder and bowel incontinence may also take place at various stages throughout the continuum of stroke care, especially at transition points or if there are changes in health status.
  2. The use of assistive equipment, clothing design and augmented assistive communication may be considered to prevent and support individuals experiencing bladder and bowel incontinence.
Rationale +-

Both bowel and bladder incontinence are common complications following a stroke, which negatively affect a person's daily functioning and may cause personal anxiety, leading to reductions in quality of life. These issues arise due to neurological damage that disrupts the control of the bladder and bowel muscles. Incontinence can result in social embarrassment, isolation, and decreased self-esteem, which can hinder recovery and rehabilitation efforts. Additionally, the fear of incontinence may restrict individuals from participating in physical activities or social events. Effective management strategies include bladder training, dietary adjustments, and medications. Individuals with stroke value a person-centred approach to care, including education and management strategies to improve bowel and bladder changes following stroke.

Performance Measures +-

System Indicators

  1. Availability of healthcare providers with expertise in bowel and bladder management as part of all stroke rehabilitation programs.
  2. Availability of inpatient and community-based education and resources for individuals with bladder and bowel dysfunction following stroke.

Process Indicators

  1. Proportion of patients admitted to hospital with a diagnosis of acute stroke who undergo a bladder function assessment during inpatient stay.

Patient-Oriented Indicators   

  1. Proportion of patients admitted to hospital with a diagnosis of acute stroke who experience issues with bowel and bladder function during inpatient stay.
  2. Proportion of individuals with stroke who develop a urinary tract infection as a result of an indwelling catheter during inpatient stay.
  3. Quality of life rating at 30 and 90 days for people who experience complications during acute inpatient admission following acute stroke, using a validated tool.
Implementation Resources and Knowledge Transfer Tools +-

Resources and tools listed below that are external to Heart & Stroke and the Canadian Stroke Best Practice Recommendations may be useful resources for stroke care. However, their inclusion is not an actual or implied endorsement by the Canadian Stroke Best Practices team or Heart & Stroke. The reader is encouraged to review these resources and tools critically and implement them into practice at their discretion.

Health Care Provider Information

Resources for Individuals with Stroke, Families and Caregivers 

Summary of the Evidence +-

Evidence Table and Reference List 10

Urinary Incontinence

Several strategies and interventions have been examined for the management of bladder incontinence post stroke. A Cochrane review 221 included the results of 20 RCTs including 1,338 individuals at varying stages of recovery. Interventions examined included behavioral interventions (pelvic floor muscle training, and timed voiding), specialized professional nurse input, complementary medicine (acupuncture, electroacupuncture and moxibustion), and physical therapy (transcutaneous posterior tibial nerve stimulation [TPTNS], transcutaneous electrical nerve stimulation [TENS] and sensory-motor biofeedback). Compared with usual care or no intervention, based on the results from a single trial, behavioral interventions did not significantly reduce the number of incontinence episodes per 24-hour period (0.2 vs. 1.2; MD= -1.00, 95% CI -2.74 to 0.74), nor were they associated with improvements in quality-of-life (SMD= -0.99, 95% CI -2.83 to 0.86). In contrast, complimentary medicine increased the likelihood of achieving continence after treatment (RR=2.82, 95% CI 1.57 to 5.07) and TENS reduced the number of incontinent episodes in 24 hours (MD= -4.76, 95% CI -8.10 to -1.41). In two systematic reviews examining the benefit of single interventions, Özden et al. 222 reported that pelvic floor muscle training was not associated with significantly better performance on the 3-day voiding diary (total) at 12 weeks (SMD=0.30, 95% CI −0.23 to 0.95), but was associated with significant improvement in daytime urination frequency and urinary incontinence, in pad tests. Cruz et al. 223 included 10 RCTS examining TENS and found that treatment was associated with significantly greater improvements in urinary incontinence measures (SMD=-1.99, 95% CI -3.48 to -0.49).

The effectiveness of bladder-training programs, which typically include timed/prompted voiding, bathroom training, pelvic floor exercises, and/or drug therapy, has been evaluated in a small number of studies. Thomas et al. 224 conducted a cluster feasibility trial, Identifying Continence Options after Stroke (ICONS). Compared with usual care, the systematic voiding program was not associated with significantly increased odds of being continent at 6 or 12 weeks. In the largest RCT ever planned on the topic of post-stroke urinary incontinence, ICONS II, Watkins et al. 225 planned to randomize 1,024 patients, recruited from 10 stroke units in the UK, to participate in a systematic voiding programme group in which patients received an assessment, and behavioural interventions (bladder training or prompted voiding) or to receive usual care. Unfortunately, due to Covid-19, only 157 patients were recruited, and the trial was halted early. Tibaek et al. 226 randomized 31 men with lower urinary tract symptoms, one month following stroke, to a pelvic floor muscle training (PFMT) group, who received 12 weekly, 60 minutes sessions + at home exercise program or to a usual care group. There were no significant differences between groups on the primary outcomes (Danish Prostatic Symptom Score and voiding frequency). In an earlier trial Tibaek et al. 227 which also examined PFMT in 24 women with stress/urge urinary incontinence, the authors reported a significant decrease in voiding frequency in the intervention group, but not the control group.

Pharmacological agents can also be used for the management of urinary incontinence, although there are few trials evaluating their use following stroke. There is a larger evidence base for their use in multiple sclerosis, spinal cord injury and Parkinson’s Disease. The use of anticholinergic medications was evaluated in a recent Cochrane review 228 which included 104 RCTs (n=47,106), mainly men with a symptomatic diagnosis of overactive bladder syndrome, detrusor overactivity, or both. Participants were randomized to receive darifenacin, fesoterodine, imidafenacin, oxybutynin, propiverine, solifenacin, or tolterodine or placebo. Anticholinergic drugs were associated with significantly greater improvements in condition-specific quality of life, and patient perception of cure or improvement, with a significant reduction in the mean number of urgency episodes per 24 hours. However, the risk of adverse events was significantly higher in the active interventions group (RR=3.50, 95% CI 3.26 to 3.75).

Fecal Incontinence

Management strategies for fecal incontinence have not been well studied in the stroke population. In the only RCT on the topic, Harari et al. 229 randomized 146 stroke patients with constipation or fecal incontinence (an average of two years post stroke) to an intervention or control group. The intervention consisted of a one-time nursing assessment (history and rectal examination), followed by patient/carer education (booklet) and provision of diagnostic summary and treatment recommendations, which was sent to the patient's general practitioner. Persons in the intervention group had an average of 5 episodes of fecal incontinence episodes at one and 6 months, compared with 12 and 6 episodes, respectively among persons in the control group. In a recent Cochrane review, Todd et al. 230 examined the use of a variety of conservative therapies and physical therapies in 1,598 participants with central neurological disease or injury, reported in 25 RCTs. Very few pooled analyses were conducted due to limited data availability. The authors concluded that some non-drug treatments, such as probiotics and abdominal massage, may improve self-reported symptoms of constipation, while others, such as holistic nursing assessment, may improve self-reported symptoms of fecal incontinence. The evidence supporting the use of probiotics and nursing assessment, is uncertain.

Sex & Gender Considerations

The incidence of urinary incontinence (UI) post stroke can vary widely from 28% to 79% and appears to be similar men and women. 231 Risk factors are also similar between the sexes and include age >70 years, intracranial hemorrhage, pre-stroke disability and stroke severity. 232 The incidence of post-stroke fecal incontinence is much lower than UI. Lucente et al. 233 reported that 6.4% of 359 patients with acute stroke had fecal incontinence within the first 72 hours of stroke onset, decreasing to 1.9% at 90 days. In the same study, increased stroke severity and hemorrhagic stroke were independent risk factors for fecal incontinence in the acute stage of stroke, while female sex, was not (OR=2.31, 95% CI 0.88–6.08).

Stroke Resources
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