A stroke often causes problems with bladder and bowel control. These usually improve in the early weeks after the stroke, but around a third of stroke survivors may have longer term difficulties. For many people loss of toilet control is a very sensitive and personal issue, and people can feel like they have lost their dignity.
This guide looks at the treatments and support that can help, and practical tips on living with continence problems.
The most important thing you can do is seek help from your GP or a member of your stroke team. They can help you find out the cause of your continence problems, and get the right treatment. Keeping it hidden could mean missing out on treatment and support. Regaining control can improve your wellbeing and your recovery.
How does a stroke affect your bladder and bowels?
Damage to brain cells
If you lose consciousness during a stroke, you could soil yourself without realising it. And a stroke can damage the part of the brain that controls your bladder or bowel. Urine retention can also happen soon after a stroke. You may find it difficult to empty your bladder and it may become very full, but this usually only lasts a few days for most people.
Mobility and communication problems
If you are having difficulty walking you may not always be able to get to the toilet in time. If you have communication problems, it may be hard to ask for help in time to get to the toilet. If you have to work harder to move around, the extra exertion can make it more difficult to maintain bladder or bowel control.
Being less mobile than usual can make you more prone to constipation (not emptying your bowels regularly. This may cause continence problems because a full bowel can put pressure on your bladder. You may not be able to eat or drink as much as usual because of the stroke, and might not get enough food and water. This can also lead to constipation.
Some medications can affect your bladder and bowels. For instance, some types of blood pressure medication may affect bladder control or cause constipation when you start taking them. If you have any questions about your medication, ask your pharmacist. Don’t stop taking any medication before speaking to your GP.
If you already had mild bladder or bowel problems before your stroke, these are likely to be made worse by long periods of sitting.
Type of bladder problems after a stroke
Frequency: needing to pass urine more often than is usual for you.
Urgency incontinence: feeling a sudden, urgent and uncontrollable need to pass urine. Often there is no time to get to the toilet, so you may have an accident.
Nocturia: waking from sleep with an urgent need to pass urine.
Nocturnal enuresis: wetting the bed while still asleep.
Functional incontinence: when the physical effects of your stroke make it difficult for you to reach the toilet or unfasten your clothes in time.
Stress incontinence: small dribbles of urine leak when you cough, sneeze or laugh. This usually happens because the muscles in your pelvic floor are weak or damaged.
Reflex incontinence: passing urine without realising it. This happens when a stroke has affected the part of the brain that senses and controls bladder movement.
Overflow incontinence: where the bladder leaks due to being too full. This can happen if you have lost feeling in your bladder and can’t tell you need to pass urine, or because you have difficulty emptying the bladder fully (urine retention).
Types of bowel problem after a stroke
Faecal incontinence: uncontrolled bowel movement. This can be caused by damage to the part of the brain controlling the bowel. It can also happen if you can’t get to the toilet in time, or if you have diarrhoea or constipation.
Constipation with overflow: large stools can get stuck and block the bowel. Liquid stools may flow around it causing watery stools to leak.
Faecal impaction: dry, hard stools collect in the bowel. They can press on your bladder and make you feel you need to empty it more often or they can make it more difficult to empty your bladder.
Getting individual assessment and treatment
It is vital you seek treatment, because most bladder and bowel problems can be improved. If you are caring for a stroke survivor with bowel and bladder problems, you should be given advice on how to help them.
Your medical and nursing team will assess and treat your bladder and bowel problems. They should help you to understand the causes of your problems, and support you to make lifestyle changes and perform exercises and training to manage your bladder and bowel.
The assessment may include:
A history of any bladder and bowel problems you had before the stroke and your current medication.
A diary recording what you drink and how much urine you pass over two to three days.
A urine test to rule out infections.
A diary of your bowel movements.
Other tests may include a physical examination, a bladder ultrasound scan, abdominal X-ray or specialist investigations to find out how the bladder and bowel are working.
Help with continence problems
If you have good bladder and bowel function but you can’t tell anyone when you need the toilet because of a communication difficulty, staff may offer you the toilet or commode every two hours or so. You could be offered a bottle or sheath urinal (designed for men) or a bedpan (for women).
Until you can start to regain control of your bladder or bowel, you may be offered absorbent pads. These should be changed immediately if they become soiled. Good hygiene and skin care are important to protect your skin from damage.
If your bladder is not emptying fully, then a catheter may be used to empty it. This involves inserting a fine tube into either the urethra or through a small hole made in the stomach to drain urine from the bladder into a bag. This may need to be done several times to keep you comfortable and reduce the risk of developing a urinary tract infection (UTI).
Which professionals can help me?
Bladder and bowel problems can be treated by a range of professionals, including doctors, nurses and therapists. Continence problems can affect all aspects of your life and your health, so you may need different types of help with your individual needs. You should get help to live well with continence problems.
Continence advisors are specialist nurses who are trained to treat bladder and bowel problems. They will fully assess your individual needs and develop a plan with you that is tailored to your personal circumstances. You may need to see a specialist consultant, such as a urologist, gastroenterologist, gynaecologist or geriatrician. Your GP can advise you and provide a referral.
Treatments for bladder problems
Once the cause of your bladder problem has been found, you will be offered advice and treatment. These can include:
Drinking plenty of fluids. Strong, concentrated urine irritates your bladder. This makes feelings of urgency worse, can cause leakage and also bladder infections. Caffeine can also stimulate urine production so you may be advised to reduce your caffeine intake.
Bladder training reduces urgency and frequency by gradually teaching your bladder to hold more urine. This is done by making regular visits to the toilet, and gradually extending the time between visits until your bladder learns how to ‘hold on’.
Pelvic floor exercises help strengthen muscles so that they provide support. This will help improve bladder control and improve or stop leakage of urine.
Electrical stimulation devices, which can be inserted in either the vagina or the anus to stimulate and strengthen the muscles that control the bladder.
Using medication to reduce feelings of urgency and frequency, or reduce the amount of urine your body makes.
Weight loss (if you are overweight) often improves bladder control in the longer term.
Stopping smoking: coughing makes bladder leakage worse. Stopping smoking can help.
Treatments for bowel problems
Advice and treatment for bowel problems may include:
Bowel retraining involves regular visits to the toilet. This is usually after meals, when the bowels are stimulated to move by a natural reflex. You also learn to delay bowel movements once on the toilet to improve your ability to ‘hold on’.
Pelvic floor exercises can strengthen the muscles that control bowel movement.
Dietary changes such as eating more fibre.
Medication: mainly laxatives to treat chronic constipation and impacted stool, which is the most common cause of leaking faeces. If you have true diarrhoea, medication can help. It is important you seek help to find out what is causing your bowel problem.
Drinking more fluids helps soften the stools.
Enema or bowel irrigation may be used to clear the bowel if faecal impaction occurs.
Help with daily life
Occupational therapists help you regain your independence through activities to support your recovery. They can also help if your home needs to be adapted (for instance by having hand rails put up) or if any mobility equipment is needed to make it easier to use the toilet, such as walking aids or a wheelchair.
Dietitians can recommend a suitable, well-balanced diet and fluid intake, as well as any dietary changes that may help you.
Community health and social care services should arrange any support that you may need once you are back at home. If you are eligible to receive a regular supply of continence products through the NHS continence service, you should also receive a regular review of your needs at least once a year. Eligibility varies throughout the UK.
Social services can help with financial issues, such as obtaining benefits, and securing any grants you may be entitled to if you need to adapt your bathroom or build one downstairs.
Practical tips on living well with incontinence
While it does involve extra thought and effort, with good advice and preparation, bladder and bowel problems can be managed discreetly as part of everyday life.
Planning ahead when you go out
Practical measures like planning access to toilets when you are out, and having a change of clothing and hygiene kit with you (which might include plastic bags for disposal or laundry, soap and flannel, anti-bacterial wet wipes and disposable gloves) will help you manage in any situation.
The National Key Scheme (NKS), also known as the RADAR Scheme, provides keys to public disabled toilets designed for wheelchair access. The scheme is available to people with disabilities or health conditions seriously affecting their continence.
The Just Can’t Wait Toilet Card is also free and available from the Bladder and Bowel Community. Showing this clearly and discretely allows you to access toilets anywhere, when you have an urgent need.
Find a routine that works for you
A daily routine of regular visits to the toilet, staying hydrated during the day and reducing the amount you drink just before bed time, will help to avoid accidents. An alarm can be used to schedule a visit to the toilet during the night, or you may prefer to try a moisture alarm on your bed, which will sound when wetness is detected. This is designed to wake you up so that you can finish emptying your bladder in the toilet.
You may wish to wear a silent vibrating alarm watch, which can be set to give a discreet reminder at regular intervals. A silent alarm also has advantages at night time if you wish to avoid disturbing others.
Practical tips and equipment
There are various continence products available, such as absorbent pants and pads. Your GP or continence adviser will be able to tell you what is provided free of charge through your local NHS and what you can buy.
Specialised products are prescribed by continence advisors or GPs. They include catheters, anal plugs, urine drainage bags and appliances for men.
Absorbent products can be purchased from supermarkets, pharmacies and by mail order or online. If you buy products from a chemist or by mail order, they can give you a form to sign so you do not pay VAT.
Keeping skin healthy
The moisture, friction and bacteria due to urine and faeces can cause skin rashes and infection. Careful hygiene and skin care are needed to avoid the risk of skin damage such as redness and blistering (incontinence-associated dermatitis).
If your skin is badly affected, an ‘indwelling’ catheter, in which the bag is attached to the leg and worn under clothing, may be recommended, though this is generally used only as a last resort. In some cases a suprapubic catheter, where the catheter is inserted into the bladder through the abdomen, may prove a more convenient method of permanent drainage. Your continence adviser should be able to explain your options.
Know your own bladder and bowel patterns and try to stick to your routine. Don’t go to the toilet ‘just in case’. Go when you feel the need to go.
Remember to follow all the bladder and bowel training tips and exercises your nurse or continence adviser has given you. It takes time for the effects to show and perseverance does give results.
Drink plenty of fluids during the day. This will help to avoid infections of the bladder and constipation. Try to have 6–8 glasses of fluid each day, and more if you have a catheter.
Cut down on drinks which contain caffeine such as tea, coffee and cola, and avoid fizzy drinks as they can irritate the bladder. Alcoholic drinks can cause dehydration.
Eat a balanced diet with plenty of fruit and vegetables. They contain valuable fibre, which helps bowel movements. Keep as active as you can. This can help to reduce bladder leakage and will help stimulate your bowel to move regularly.
Try not to use the toilet unless you need to, and empty your bladder fully when you go. Sometimes sitting for longer can help to empty your bladder, or you could try standing up and sitting down again. This can also help to avoid infections.
Wear clothes that are quick to remove, such as trousers with Velcro fastenings or elasticated waistbands.
Carry a Just Can’t Wait card or download the Just Can’t Wait app, available free from bladderandbowel.org. A RADAR key is also available from the website and can help you gain fast access to public toilets.
Take care of your skin by using mild soap or specialised products and take care to clean and dry thoroughly.
Dispose of wet or soiled products safely. Ensure that disposal bags are secure and leak-proof, and use a bin with a lid.
Help for carers
You may feel out of your depth when faced with incontinence, even if you are emotionally and physically strong. You and your loved one may well find it difficult to preserve their comfort and dignity while following a toileting routine, giving and receiving intimate care or dealing with soiled clothes and bed linen.
You may find it useful to speak to a specialist continence adviser or one of the organisations listed in ‘Other sources of help and information’ in this guide. They will be able to talk through your questions and concerns, help you to consider all of the options, and make practical arrangements for the longer term.
Our Stroke Helpline can put you in contact with your local carer support services.