A urinary incontinence service for patients with chronic cough

Abstract

Approximately one-third of female patients at a chronic cough service reported experiencing urinary incontinence but noted this was not addressed in their care. As a result, a nurse-led service was developed to assess and manage this symptom in patients with chronic cough. All new patients are now routinely asked about it during their initial consultation, and those who report it are referred to the clinical nurse specialist for advice and support, and further referred as appropriate.

Citation: Hennessey S (2023) A urinary incontinence service for patients with chronic cough. Nursing Times [online]; 119: 4.

Author: Sarah Hennessey is clinical nurse specialist – chronic cough, Manchester University NHS Foundation Trust.

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Introduction

Manchester Chronic Cough Service is one of few tertiary services for patients with chronic cough in the UK. It is multidisciplinary and comprises physicians, speech and language therapists, and the UK’s first chronic cough clinical nurse specialist (CNS).

Chronic cough can contribute to urinary incontinence (UI), which can negatively affect a patient’s physical, psychological and sexual health (Coyne et al, 2013). Of the women who attend our service, 32% reported experiencing UI; however, the symptom is often underreported by patients due to embarrassment and, as such, goes untreated (Shih et al, 2017).

In 2019, we conducted an audit of new patients. It revealed that, for many who reported experiencing UI, it was not addressed as part of their treatment for chronic cough. As a result of this audit, we developed a nurse-led service to support, assess and manage UI in patients with chronic cough (Hennessey et al, 2021).

Patient experience

During their consultations with the CNS, both new and existing patients often described symptoms of UI and how this was adversely affecting various aspects of their life, including:

• Needing to carry a change of clothes and underwear;
• Avoiding activities, such as attending the gym and dancing;
• Feeling self-conscious and avoiding activities previously enjoyed due to embarrassment, often leading to feeling depressed;
• Performing less well at work due to needing more-frequent toilet breaks to change underwear or pads, and worrying employers would question their performance.

The CNS was inspired to help these patients to enjoy and continue everyday activities without worrying about UI, thereby improving both their quality of life and outcomes.

Service implementation

Before our service was developed, clinicians in Manchester – and likely across the UK – focused on managing chronic cough rather than UI: there was no service for patients with both chronic cough and UI. In other areas of the UK, patients are often seen by general local continence services that do not fully understand both the impact and specialist management of chronic cough.

Now, patients with UI in Manchester receive more-specific advice, support and management, which allows them to overcome barriers caused by embarrassment or a lack of awareness about the condition. Our service offers these patients both psychological and physical support.

We now routinely ask all patients with chronic cough about UI during their initial consultation. Those who report UI are referred to the CNS, who offers:

• Advice;
• Education about pelvic floor exercises;
• Lifestyle management guidance;
• Referral or signposting to local UI, women’s health physiotherapy, urology or gynaecological services, as appropriate.

Introducing the CNS role has provided a more-responsive, patient-centred service. It has also shortened the chronic cough patient pathway from referral to diagnosis and treatment by freeing up time for doctors to see new patients or those with complex needs.

The CNS has undertaken training in the assessment and management of UI; because the service is unique, we have developed and tailored this to the needs of our patient cohort. The CNS has developed a pro forma tailored to patients with chronic cough to enable comprehensive assessment of UI and ensure each patient receives holistic, standardised, evidence-based care. We have developed links with local, regional and national services, showcasing the CNS’s work to promote the benefits of the service and inspire other respiratory services across the country to improve patient outcomes.

“This category winner challenged themselves, responding to a gap they identified in the patient’s healthcare journey, recognising the multifaceted nature of continence to drive innovative change.” (Judges’ comments)

Outcomes

Patients with chronic cough are now assessed for UI symptoms from their first appointment onwards, and have a clear pathway for assessment by the CNS. The service has improved access to care and support for patients who also experience UI, improving their holistic care. Of the 32% of patients who reported UI, 92% consented to a referral to the CNS for further advice and support, and most were seen within six weeks of their initial consultation.

We conducted an audit to compare patients’ UI quality of life (UIQOL) scores before they received input from the CNS and six months after they completed the intervention. A UIQOL score of zero meant their quality of life was not affected by UI, and a score of 10 meant it was significantly affected. The audit showed that the mean UIQOl score reduced from 7.4 to 3.6 and 94% of patients reported improvement in symptoms and quality of life. One patient said:

“For the first time in three years, I now feel in control of my cough and incontinence. As a direct result of efficient and effective input from both services, all the barriers to my condition were removed. I was actually of the opinion I would have to live with this. I now realise that incontinence can be effectively treated, regardless of the medication that is required to support respiratory care.”

Health professionals in our chronic cough service are now more knowledgeable about the impact of UI with chronic cough, and work together to improve overall patient outcomes. Doctors now recognise the need to ask patients about UI during their initial consultation, and refer them to the CNS if symptoms are reported. The team’s speech and language therapists are also more aware of the importance of UI with chronic cough and refer patients with symptoms to the CNS.

We have built a close network with local and regional bladder and bowel services. The CNS works collaboratively with bladder and bowel teams across the country to:

• Provide combined care;
• Access local services for patients, such as women’s health physiotherapists.

The service has broken down barriers to patients accessing services. We have seen that they now report UI more often because it is addressed during their initial consultation. Verbal feedback received by the CNS teaches us that many patients had previously not recognised UI was a common problem associated with chronic cough and had felt too embarrassed to seek help. The service has reduced the taboo nature of UI.

Other cough teams across the UK have contacted us to ask for advice, request the CNS’s job description and discuss setting up a similar service in their locality. Other respiratory services in our trust (for example, severe asthma) have also asked our CNS for advice and to see their patients who report UI.

Future plans

The CNS’s promotion of the service – for example, in Hennessey et al (2021), at conferences and to relevant networks – has led to several enquiries from other centres hoping to develop similar roles and replicate the service. Doing this in chronic cough clinics, other respiratory areas and primary care will allow more patient cohorts to benefit from more-effective holistic care and improve patient outcomes on a much larger scale.

As the pathway and pro forma are easy to follow and self-explanatory, they can easily be shared so the initiative can be implemented in other areas and care standardised across different services. Although developed for patients with chronic cough, they can be adapted to specific patient needs in other nursing disciplines.

Conclusion

After identifying that around one-third of the clinic’s female patients reported experiencing UI that was not addressed by health professionals, we developed a nurse-led service to assess and manage this symptom in patients with chronic cough. All new patients are now asked about UI during their initial consultation; those who report experiencing it are referred to the CNS, who advises, supports and signposts them as appropriate.