Urinary and bowel elimination are essential to maintain health. The urinary system consists of the kidneys, ureters, bladder, and urethra. Urinary incontinence occurs when abnormalities of the structures of the urinary system, nervous control of the detrusor muscle, or the urinary sphincter cause an uncontrolled loss of urine, resulting in social, physiological, or hygienic difficulties for a client.

The upper urinary tract includes the kidneys, renal pelves, and ureters. The outermost part of the kidneys, the parenchyma in which urine is formed, is made up of nephrons. Urine drains into the renal pelves through the ureters to the bladder. The renal pelvis and ureters are smooth muscles, so they deliver urine to the bladder with peristalsis, or muscle contraction.

The lower urinary tract consists of the urinary bladder, urethra, and pelvic muscles. The bladder is made up of smooth muscles known as detrusor muscles. Urine is eliminated through the urethra. A micturation center in the brain controls urination. When the bladder fills up with urine, the sympathetic nervous system is stimulated, the detrusor muscle relaxes, and the urethral sphincter contracts. Voiding occurs through the parasympathetic nervous system, which causes contraction of the detrusor muscle and relaxation of sphincter muscles.

The factors affecting bowel continence are the consistency of the stool, or fecal material, intestinal motility, compliance and contractility of the rectum, and competence of the anal sphincters. The gastrointestinal (GI) tract (alimentary canal) includes the stomach, which collects the food and begins the digestive process; small intestine, which absorbs nutrients; the large intestines, which absorb fluids and remaining nutrients; and the rectum, which stores waste until elimination occurs. The digestive chime (mixture of partially digested food and secretions) passes out of the stomach and into the small intestine where nutrients, vitamins, minerals, fluids, and electrolytes are digested and absorbed; through the ileocecal valve; and into the large intestine, which collects, concentrates, transports, and eliminates waste (feces).

Feces are stored in the rectum until defecated (evacuated). If the feces are not evacuated, the rectum overdistends, the stool hardens, and the person is constipated. The anal sphincters are the structures that help the person have a bowel movement. The internal sphincter are made up of smooth muscles and innervated by sympathetic nerves. The external sphincter is made up of striated muscles. When the rectum is distended with feces, the internal sphincter is inhibited and the external sphincter is stimulated to contract, holding the feces inside the rectum. The external sphincters then relax as the person strains to defecate.

The factors affecting both urinary and bowel elimination are age, diet, exercise, and medications. The primary cause of constipation is inadequate fluid intake. There are four types of urinary incontinence: stress urinary incontinence (SUI), urge incontinence, functional urinary incontinence, and extraurethral incontinence. Stress urinary incontinence (SUI) is an uncontrolled loss of urine caused by physical exertion in the absence of a detrusor muscle contraction. SUI, associated with urethral hypermobility or intrinsic sphincter deficiency, occurs with coughing, jumping, sneezing, or other activities that increase abdominal pressure on the bladder.

Urge incontinence is involuntary leakage accompanied by or immediately preceded by an urge to void. The two types of urge incontinence are urge urinary incontinence (overactive bladder) caused by detrusor overactivity, and reflex urinary incontinence, caused by spinal lesions above S-2. Functional urinary incontinence results from the inability to mobilize, handle toileting needs, access a toilet, or think through how to use the bathroom. Extraurethral incontinence is the uncontrolled loss of urine that exists when the sphincter mechanism has been bypassed; it is caused by a congenital defect, a fistula, or a surgical bypass of the urinary bladder. Another urinary problem is urinary retention, which is caused by bladder outlet obstruction and deficient detrusor muscle contraction strength.

Bowel problems include constipation, diarrhea, and fecal incontinence. Constipation is the infrequent and difficult passage of hardened stool. Constipation can be caused by inadequate intake of fluids or dietary fiber, diverticular disease, neuropathic conditions, functional limitations, certain medications, and pelvic prolapse (in women). When severe, the hardened stool is caused an impaction.

Diarrhea is the passage of liquefied stool of increased frequency and consistency, caused by infections, malabsorption syndromes, medications, enteral feedings, the misuse of laxatives and enemas, and hyperactivated intestinal mechanisms. Fecal incontinence is the involuntary loss of stool, which can be caused by the inability to toilet (functional incontinence), low compliance of the rectum, anal sphincter dysfunction, sensory disorders, and anatomic disorders.

The nursing process, when applied to elimination, includes an elimination history and a physical examination that includes a functional evaluation and mental status examination. When questioning the client, it is important to determine the duration of the problem, the client’s description of the problem, the form of incontinence, activities or factors preceding the incontinence, and previous treatment. The physical examination of the woman includes an inspection of the vagina, perineal area, and perianal area. A rectal examination is done on both sexes: on men to determine whether the prostate is enlarged, on women to determine weaknesses in the vaginal and rectal walls, and on both to determine whether hemorrhoids are present. Clients with urinary incontinence may be asked to keep a voiding/incontinence diary. Laboratory tests include urinalysis and stool culture. Urinalysis can detect the presence of blood, protein, and bacteria. Pyuria refers to the presence of white blood cells, and bacteriuria means bacteria in urine.

Nursing diagnoses related to urinary and bowel alterations include Impaired Urinary Elimination, Stress Urinary Incontinence, Reflex Urinary Incontinence, Urge Urinary Incontinence, Functional Urinary Incontinence, Total Urinary Incontinence, Urinary Retention, Constipation, Perceived Constipation, Diarrhea, and Bowel Incontinence. Nursing interventions to maintain elimination health include teaching the importance of fluid intake; avoiding foods and beverages that may irritate the bladder (e.g., caffeinated beverages, carbonated drinks, acidic food or drink, chocolate, or greasy or spicy foods); maintaining an exercise plan, including pelvic muscle exercises; and modifying the environment to facilitate self-toileting.

Bladder and bowel training (toileting at planned intervals) can be used to reestablish habits. Bowel training also includes rectal stimulation (palpitation of the anal sphincter and distal anus for 2 to 3 minutes) and stimulating a bowel movement at regular times through enemas or suppositories. The nurse should also monitor for skin integrity and apply containment devices (condom catheter, incontinence and dribble pads, rectal pouch, and rectal tube) if necessary to prevent skin breakdown. Medications, such as imipramine (Tofranil) and topical estrogens, can be used to manage urinary incontinence. Anticholinergics or antispasmodic may be given to relax the detrusor muscle. Occasionally, a urinary catheter is used for urinary retention. Self-catheterization is used for women with reflex incontinence. Enemas may used to cleanse the lower bowel.

Some clients have been subjected to surgical procedures that produce incontinence. For example, the ileal conduit constructs a pouch for the collection and drainage of urine. Bowel diversions, such as ileostomies and colostomies, are done for malignancies or irreversibly damaged bowel tissues. These procedures result in the formation of a stoma on the abdomen. The client’s responses to incontinence and its management should be evaluated continually to assure expected outcomes are being met.