Feeling Good
Acceptance, self-esteem and self-advocacy
Continence-Incontinence
Health and Health Care
Obesity/Weight Loss
Pain/Pain Control
Relationships/ Dating
Sex
Sports/Leisure
Stress/Destressing
Acceptance, self-esteem and self-advocacy
Continence/Incontinence
Sharon Groff RN, NCA (more on Sharon at About this Site/Advisors) answers questions on incontince and other bowel and bladder related problems below.
Sharon also runs a continence care clinic for older people at the Hotel Dieu Shaver Health and Rehabilitation Centre on Glenridge Ave. in St. Catharines every other Friday. The clinic is free and you amy make your own apppointment by calling 1-905-573-4821 or your family doctor may make an ppointment for you by calling 1-905-560-1574.
Q: What does NCA stand for? A: Nurse Continence Advisor
Q: What made you go into this line of work? Why do you do it? A: During my school years, I was always the one to raise issues that everyone else just whispered about. It used to get me in a whole lot of trouble. When I attended a continence conference in 1998, I determined that this was another issue that needed to be brought out into the open because of the devastating effects it has for people suffering in silence when faced with incontinence. It made me realize that I could relate to these people and by helping them I could also help myself. So, a continence advisor was born.
Q: I have what I think is called stress incontinence. When I laugh sneeze or cough, I pee my pants. Not a lot but enough to make me aware of it. What causes it, will it get worse and what can I do for it? A: Although stress incontinence is more common in women it can sometimes occur in men. Stress incontinence is the result of a physiological change. In order to remain continent, the full bladder relies on the pelvic floor muscles to keep the neck of the bladder and the urethral sphincter closed during times when abominal pressure is raised such as when you cough, laugh or sneeze. When the pelvic floor muscles have been weakened, they sag and can no longer support the full bladder. This causes the bladder neck to drop through the pelvic floor forcing urine past the urethral sphincter resulting in the involuntary loss of urine. The causes that researchers agree on are: being born with a weak sphincter, pelvic damage or damage from childbirth, removal of prostate, radiation therapy, spinal cord lesions, lack of estrogen, postmenopause and factors contributing to conditions causing increases in abdominal pressure such as lung conditions (coughing), constipation (straining) and weight (obesity). Factors that make stress incontinence worse are: medications ("water pills" because they produce more urine), or medications that cause relaxation of the urethra, caffeine (causes frequency, urgency and more urine to be produced), impaction of stool, diabetes and environmental barriers(not allowing you to toilet in time). Stress incontinence can be managed with one therapy or a combination of therapies depending on your goals, preferences and other factors that could influence treatment outcomes. All treatments are designed to increase resistance on the urethra. After behavioural therapies other options include: pelvic muscle re-education (Kegel's exercises) with or without biofeedback, hormone replacement therapy unless contraindicated, medication, surgery, pessary and absorptive products. All of these measures offer a variable degree of improvement but should not be considered as a "cure".
Q: I have a neuromuscular disorder that makes my legs weak and I can no longer get off the toilet by myself, especially if it is a regular toilet. I want to be able to go out and enjoy myself but find I can’t use a public toilet, which means I have to limit my outings to day trips no longer than four hour. I’m afraid I’ll never be able to travel again. What would you suggest? A: If you are going out for the day and are only concerned about bowel issues, bowel routines can often be effective for having movements when you want to have them, say in the morning before leaving. If you are concerned about both urinary and bowel issues, there are a number of protective products that could be considered. These products are designed for both urinary and bowel containment and are designed to hold a significant volume odourlessly and effectively.
Q: I can’t seem to make it to the toilet on time no matter what. I’ve stopped drinking to almost nothing but it only seems to be worse? What can I do? A: This is probably the most common approach that people use when they have urinary incontinence. In fact this approach may have been suggested to them. The truth of the matter is, contrary to what seems to make sense is that not drinking enough fluid can make urinary incontinence worse not to mention the constipating effect that it has on the bowel which by the way can also make urinary incontinence worse. There is a muscle in the bladder called the detrusor muscle. When the bladder is full, this muscle contracts which sends a message to the brain asking the brain to relax the muscle that holds back the flow of urine. The muscle relaxes, the detrusor continues to contract pushing the urine out. When the urine is not diluted with enough fluid, it becomes concentrated. This irritates the bladder muscle and it start to contract even if the bladder is not full. The brain, not recognizing that the bladder is not full, responds to the contraction and relaxes the muscle that holds back the flow of urine. This results in voiding even if there is only a small amount of urine in the bladder. If you do not respond to this urge to void then the bladder will squeeze the urine out and you will leak. On the other hand, if you continuously respond to this urge, the bladder then learns to respond with very small amounts of urine in it resulting in frequency of urination along with urgency. When you consume adequate fluids the bladder muscle remains relaxed and will allow the bladder to reach it's normal fullness before giving you the feeling of having to go. This usually occurs around the 3-4 hour mark. The amount of fluid required on a daily basis is tailored to the individual. Some people may require less fluid due to underlying medical concerns. One size does not fit all.
Q: I work in an office and lately have found that I’m using the washroom two or three times in the morning and again in the afternoon. This isn’t like me. I drink coffee in the morning before I go to work, one my break at 10:30 and one at lunch and then switch to tea in the afternoon. I’m 60 years old. Could it be the coffee and tea or is it something hormonal? A: The answer to this question is that it could be both. Caffeine works both on the kidneys and the bladder. It causes the kidneys to output more fluid than has been taken in. This is why you can still feel thirsty after drinking coffee or tea. The kidneys filter this fluid through very quickly and dumps it into the bladder. Because the bladder can not stretch fast enough to accommodate all this volume you get an urgent feeling that you have to get to a bathroom quickly. If you are unable to respond fast enough the detrusor muscle, irritated by the caffeine will contract and push out the excess volume and you will experience incontinence. After menopause, the amount of estrogen in the female body declines. It is thought that this decline can produce irritative symptoms such as burning when voiding, urgency, frequency, nighttime incontinence and stress incontinence. If the use of estrogen is not contraindicated you may want to discuss the use of a vaginal estrogen with your physician. This is the route that is generally recommended for the treatment of the above symptoms.
Q: When I have to take antibiotics for something, I find I get terrible diarrhea. I dread taking antibiotics because of that. Anything I can do to stop the diarrhea? A: Antibiotics disturb the "good" and "bad" bacteria in the intestinal passage causing the "bad" bacteria to grow beyond the normal level. This results in frequent watery bowel movements. This situation should clear up a few days to two weeks after you stop taking the antibiotic. If diarrhea continues past that and you experience abdominal pain, fever and bloody loose stool you should contact your healthcare provider. For mild diarrhea drink plenty of fluids but avoid carbonated beverages, citrus juices, alcohol and caffeinated drinks such as coffee, tea and colas. Eat foods that are easy to digest such as rice, plain baked potatoes, yogurt and bananas. Avoid most other fruits and their juices as well as dairy foods. Eat small meals throughout the day since they are easier to digest. Stay away from spicy, fatty or fried foods or any foods that you have found to make the diarrhea worse. Recently you have probably read about probiotics. These are supplements of "good" bacteria similar to those that occur naturally in your intestinal passage. These supplements may prevent diarrhea that results from the use of antibiotics. Some studies have found these supplements to be effective while others have not. These supplements can be found in drugstores, natural food stores and some grocery stores. They come in both liquid and capsule form and may need refrigeration. Yogurt labelled as having live cultures (Lactobacillus acidophilus) may help to reduce the incidence and severity of diarrhea resulting from antibiotic use. S boulardi, a form of yeast has been shown to help protect against diarrhea associated with antibiotic use and inflammation of the colon. If you have a yeast allergy or HIV/AIDS, talk to your doctor before trying this supplement. Never take anti-diarrheal medications without first consulting your doctor.
Q:My doctor put me on medication for pain. Two days later, I stopped having bowel movements. It has been 10 days and I’m feeling very uncomfortable. What can I do? He didn’t say anything about this and no one has said anything about how to treat the constipation. I have to take the pain medication. Will I be like this from now on? A: Constipation can be the result of taking some medications for pain particularly those known as Opioid Analgesics. These are the ones that are often used to control moderate to severe pain or are used before and after surgery. Normally, the smooth muscle of the large colon contracts intermittently and the hair like fibres propel the stool along into the rectum. This is referred to as colonic transit time. Opioid analgesics interfere with the colons ability to contract and they decrease propulsion of the stool through the colon. Therefore the stool remains in the colon longer allowing more fluid to be removed from the stool resulting in harder, drier stool. They can also have a depressant effect, altering your sensation of having to have a bowel movement and they can reduce activity level. When the stool spends prolonged periods of time in the rectum this can cause hardening and further drying of the stool which makes it even more difficult to pass. The Catch 22 of the situation is that in order to have regular bowel movements people must be relaxed. If you are in pain, you are not able to do this. Therefore indirectly, pain medication may be necessary to promote relaxation . It is important to note that nausea, vomiting and/or abdominal pain may indicate that there is an obstruction in the bowel and if these symptoms are present, the first line of treatment is to go to the ER at your hospital. If your bowels have not moved for 10 days, there is likely a build-up of stool in the colon. The aim of treatment initially is to empty the rectum completely and maintain stools of a manageable consistency. Daily micro-enemas or suppositories may be given and may need to be continued for between 7 and 14 days. This regime should not be started without consulting your physician. Once the rectum is emptied the goal is to achieve and maintain a pattern of normal bowel elimination that will prevent constipation. The literature suggests that all individuals using opiod analgesics should have a bowel routine in place and this routine should be tailored to the individual. Normal bowel movement frequency usually ranges from at least 3 stools a week to a maximum of 3 stools a day.
Q: I use an electric wheelchair all day and am in bed all night. I just don’t get any real exercise and I’m finding my bowels don’t move more than once every three days and even then it’s really difficult to go. I can’t fix the not being able to walk situation but there must be something I can do to help me stay regular and more comfortable. A: The movement of stool into the rectum has been shown to be influenced by physical activity. When one thinks of exercise walking comes to mind. However, exercise can take many forms. For individuals that are unable to walk there are exercises that can be performed in their chair or bed such as pelvic tilt, low trunk rotation and single leg lifts. Whether by themselves or with assisstance, these should be done for 15-20 minutes at least twice a day. Although exercise is important for prevention of constipation it is only one of the factors that need to be considered when attempting to establish regular bowel movements. Low fluid intake has been linked to the slow movement of stool through the colon and low stool output. The amount of fluid that is considered as an adequate amount will differ from individual to individual. It is generally thought that at least 1500 ml of fluids(6- 8oz.glasses) per day is what is necessary to avoid constipation. Again, it is important to point out that this may not be recommended for someone that is on a fluid restricted diet or for someone that has other underlying medical conditions. Water is the preferred choice although other fluids such as juices are also beneficial. High fibre diets have also been found to increase stool frequency and to be effective in prevention of constipation. When fibre passes through the colon it draws water into the stool resulting in softer, bulkier stools. When the stool is of this consistency it moves through the intestines more quickly. There are two types of fibre, insoluble and soluble. Insoluble fibre is found in wheat bran, vegetables and whole grains. Soluble fibre is found in oat bran, barley, some beans and certain fruits and vegetables. Insoluble fibre does not dissolve in water and is more effective in preventing constipation. Most literature recommends between 25 to 30 grams of fibre per day. Fibre should not be recommended for individuals on fluid restriction (less than 6-8oz glasses of fluid/day). Stool softeners and a stimulant combination may be a more appropriate management for this group. Bulk laxatives (cellulose, psyllium preparations) are not recommended for people that are taking medications that may not be absorbed completely because of the added bulk in the intestinal tract or for indivduals that have a narrowing in their intestine or a bowel that does not illicit contractions. This may result in obstruction because the large bulkier stool is not being propelled through the intestine. In order to assure that any bowel routine is effective, it is important to toilet regularly and consistently. Individuals should toilet about 30 minutes after breakfast or the evening meal . Eating stimulates peristalsis (movement of food from the stomach into the intestines) which may give the person the urge to go. Even if no stool is passed at these times, it is important that the person continue to do this in order for a routine to be established. They should also be encouraged to sit with their feet slightly elevated, leaning forward with their forearms supported by their knees. This causes the diaphragm to move down. Their throat should be closed . They need to be relaxed before opening bowels. They should "brace" or widen waist for effective movement and they should relax the outer opening of the rectum instead of squeezing it. (This can be learned by practising defecatory muscle exercises at a similar time each day. Regular practising should also stimulate the bowel to work more effectively).
Q: Can you tell me about catheters? The doctor’s say I’ll likely need one soon and mentioned a Foley and suprapubic. Can you explain what they are, how they work and can I manage them with weak finger and hand strength and limited arm strength and movement? A: Telling you what a catheter is and what it does is the easy part. How an individual feels about using a catheter is the hard part. I have had clients that view the use of a catheter as "the end of the road" because they see it as a need to control a normal bodily function with an invasive device. I have others that view their use as "a beginning" in that they provide them with a sense of freedom and independence because they no longer have to worry about wetting and being embarassed. However it is viewed, the decision to catheterize should only be considered where other options are inappropriate or ineffective and should never solely be based on convenience. Long term catheterization is a an apparent solution to a problem however, it is rarely completely free from complications. Collaborative planning of care between the individual and the healthcare provider (ie.nurses specialized in the area of incontinence) can often find solutions that allow incontinence to be managed without catheters. Nevertheless there are some people for whom catheterization can be the most appropriate form of care (ie. people with difficulty in complete emptying of the bladder often as a result of neurological disease or injury, people with bladder outlet obstruction who may be unfit for surgery, and people who are chronically incontinent, often associated with debility or confusion for whom alternative methods are inappropriate or unsuccessful). It is important that the decision to catheterize be a joint one between the individual, carer and the healthcare professional and should never be made solely for the convenience of other than the individual. An indwelling catheter may be inserted into the bladder through the urethra or through a small incision into the bladder (Suprapubic meaning above the pubic bone). The foley catheter is the most commonly used in both methods of insertion. It is a long tube that has two ports on the end not inserted into the urethra. One port is to allow for urine drainage (which you connect to a collection bag) and the other port is where the saline is inserted into the balloon which when inflated keeps the catheter from falling out. Catheters are made from a number of different materials and they come in different sizes with different balloon sizes as well. The overall goals are to minimize friction during insertion and to use the smallest size catheter that allows good drainage. The normal size for women is 12-14Ch and the normal size for men is 12-16Ch. If there are complications using these sizes a larger size may be appropriate. Often the larger sizes are used after urological procedures. Large catheters and balloons are associated with an increase in bladder irritability, causing bladder spasms and subsequent leakage of urine. They may also cause occlusion of the paraurethral glands which produce the mucous lining of the urethra which protects against infection that can travel up the catheter into the bladder. Larger balloons sit higher in the bladder allowing a larger amount of leftover urine to collect below them. This can result in leakage of urine or can result in infection. The choice of drainage equipment needs to be matched to the abilities of the individual in order to promote independence and self-care. The choice of the outlet valves on the drainage equipment is subject to the person's abilities. All outlet valves are designed to be opened with one hand.There are drainage bags with turn tap outlets, push across outlets and pull down outlets. The type of outlet chosen is subject to individual preference. Likewise the choice of drainage bags. Try different types until you find one that you are able to manage with minimal difficulty. Complications from long term use of Foley catheter are: tissue damage in the urethra which can range from swelling to excessive bleeding, tissue damage in the bladder, tissue trauma on insertion and removal (recommendation for removal of Foley is every 4 weeks or before if there are complications), catheter associated infection, and catheter encrustation (deposit of mineral salts on both the opening of the catheter and on the catheter itself). Insertion of a Suprapubic catheter may be the method of choice following urethral ar pelvic trauma,or for urinary retention or voiding problems related to a prostate obstruction or a narrowing in the urethra. Suprapubic insertion can also be the choice for people with restricted hip mobility (arthritis), those with scarring of the urethra resulting from trauma or tumours, or those that are sexually active. There are advantages to catheterization using this route. There is no risk of urethral injury on insertion or removal, there is greater comfort for those people that are chair- bound, entry site makes it easier for cleaning and catheter change, more freedom for expression of sexuality and through clamping it allows assessment as to whether the bladder can work on it's own. It is inserted under local or general anaesthetic. Once this channel has been established, the initial catheter change can be done either by experienced nursing staff or by the individual and/or their caregivers. Replacement of Suprapubic catheters must be done as soon as possible otherwise, the fibres of the bladder muscle may contract and the opening to the track may close over. I could go on and on but I trust that this will give you enough knowledge to make an informed choice.
Q: Sometime my bowel movement is white or light yellow. Can you tell me why? Should I be worried. A: Stool can present in a variety of colours. All shades of brown and even green are considered normal. Stool colour rarely indicates a potentially serious intestinal problem. The colour of the stool is generally influenced by what you eat as well as by the amount of bile (yellowish-green fluid that digests fats). Green stool can indicate that stool is moving through the large intestine too quickly which doesn't allow the bile to breakdown completely. This can result from eating green leafy vegetables, green food colouring such as in Kool-Aid popsicles or iron supplements. Light-coloured, white or clay-coloured can indicate a lack of bile in the stool. This may indicate that the duct that secretes bile is blocked. Certain medications such as Kaopectate, and Pepto-Bismal and other anti-diarrheal drugs can cause this colour change. If the stool is yellow, greasy and foul-smelling, this could be indicative of excess fat in the stool perhaps due to a malabsorption problem. Sometimes the protein gluten, such as in celiac disease may cause this colour change. Black stool can be indicative of bleeding in the upper gastrointestinal tract (stomach). Iron supplements, Kaopectate, Pepto-Bismal or black licorice can cause this change. Bright red stool can be indicative of bleeding in the lower intestinal tract (large intestine,rectum) although red food colouring, beets cranberries, tomato juice or soup, red Jell-O or Kool -Aid can be responsible for the colour change. If you are concerned about the colour of the stool discuss this with your doctor. Bright red or black stool may indicate the presence of blood and you should seek prompt medical attention. White stool at any age is not normal . This colour is indicative of a lack of bile and can indicate a serious underlying problem such as a liver infection or a blockage in the passage that secretes bile such as gallbladder stones etc. If your stool is this colour you should contact your doctor.
Q: Over the past year I have noticed that my urine is sometimes pinkish. What can case that? Last week it looked like red wine. I have an appointment with my GP. Should I be concerned? A: The kidneys filter out liquid that are by-products from what you have been eating and drinking as well as other waste materials including dead blood cells, excess water,salts and minerals, urea from protein digestion, uric acid, creatinine from muscle breakdown, hormone waste and toxins. Urochrome ( yellow colouring resulting from processing of of dead blood cells in the liver) is also excreted and this is what gives the urine a pale yellow colour which is the normal colour. The colour of the urine can be the result of certain foods that have been eaten or can indicate problems, diseases or imbalances in your diet. Clear urine can be the result of excess water intake, excess caffeine intake or diuretic medication and typically is nothing to worry about if it happens occasionally. Yellow urine could be the result of excess sweating or an indication that you are not drinking enough fluids. Dark yellow urine could also indicate that you have not been drinking enough fluids. It could also indicate liver problems or jaundice. Be sure that you are drinking enough fluids before you panic. Orange urine can result from eating too many carrots or from an excess of Vitamin C. Brownish urine can be the result of having recently eaten fava beans or of having taken a laxative. It could also be an indication of a serious condition and you should see your doctor. Greenish urine can be indicative of a urinary tract infection or bile problems. Certain drugs can also cause the urine to turn greenish. A brighter green is an indicator of an excess of B vitamins. Urine that appears bluish can be an indication of high levels of calcium or can be caused by a psuedomonas bacterial infection. There are a number of things that can cause the urine to have a red tint. A bladder infection, kidney stones or bladder stones can result in reddish coloured urine. An injury to the kidneys or bladder can result in bleeding into the urine. If you think that you are seeing blood in the urine, it is a good idea to see your doctor. Reddish-purplish can be the result of eating beets. Acidic urine will turn red after eating blackberries. Alkaline urine will look reddish after eating rhubarb. If you have been handling lead or mercury and your urine is red, you should see your doctor. If your urine has a strange colour and you cannot attribute it to anything that you have been eating you should see your doctor. Also if the urine has a bad odour it may be an indication of disease.
We'll post more questions and answers from Sharon as we receive them. If you have questions relating to continence and incontinence send them to linda@lindacrabtree.com.
Health and Health Care
Dentist - we need to know dentists who have accessible offices and can work on you in your wheelchair. Anyone know a dentist who makes housecalls?
Dental Hygienist - we need to know a dental hygienist who will come to your home.
Doctor/Clinic - Anyone know a doctor who makes housecalls?
Nurse - CCAC can provide you with a personal support worker (PSW) or Nurse (RN) who will come to you if your needs are such that you need home care. see CCAC under servces.
Occupational Therapist
What is an occupational therapist? Occupational therapy is a health care profession that is concerned with a person's ability to perform activities of daily life. Activities may include: personal care, work, home, school or leisure-based function. Their predominant interest is to facilitate maximum functional independence in self-care, productivity and leisure.
An occupational therapist may be accessed through CCAC. Service will be free, however, the number of visits are limited. If more work is needed or your situation isn't something CCAC would cover, a private OT may be what is needed. Insurance will often pay for a private OT.
Private Occupational Therapists
Penny Doncaster Occupational Therapy Services – Operated by Penny Doncaster (Occupational Therapist). Penny completed her training as an Occupational Therapist at the Derby School of Occupational Therapy (UK) in 1987. Since this date, Penny has relocated to Canada, where she worked in Goderich (1990) until eventually settling in the Niagara Peninsula (Jan. 1994). For the duration of this time, Penny has worked through sub-contracted services to the CCAC (School Health, Community Adults & Pediatrics), Veteran’s Affairs and private payee’s, providing comprehensive Occupational Therapy services to adults, seniors and children with physical, learning and developmental challenges across the Niagara Region. She comes to you.
Penny finally established her own private practice in 2008. She services adults, seniors and children in the Niagara, Hamilton, Burlington and Oakville areas. She can help you access appropriate equipment i.e. ramps, lifts, bathroom equipment etc. and will write support letters to help access charitable/government funding. She can provide individualized or, group rehabilitation programs to help you achieve specific goals.
Penny also works with children who are having difficulties at school and home with their fine, gross motor and sensory processing skills. She can advise on relevant equipment needs for school and home and can liase with teaching staff on your child’s specific requirements. If a child is having problems with their functional abilities at home or at school, Penny can help.
To reach her call 905-468-9290 or e-mail her at otpenny@gmail.com
Obesity/ Weight Loss
There are all kinds of weight loss programs but none may be geared to or god for people with disabiities or seniors. We fall through the cracks. I believe there is a weight loss program pffered st the St. Catharines General Hospital and I'll look into it. If anyone knows more about it please get in touch with me. - linda@lindacrabtree.com
PAIN AND PAIN CONTROL
A huge subject and we'll add to it as we learn. If you have tried something that has truly helped you control chronic pain please let us know. I've had chronic neuropathic pain for more that 15 years and have found many things that don't help and several things that do. I'll put them here within the next week.
RELATIONSHIPS AND DATING
SEX
Sex - We know of several excellent books on sex for people with disabilities and seniors. We'll put them in the Publications section. If anyone has questions on sex or sexuality pertaining to people with disabilities, seniors or caregiving please ask. We have an expert who will answer your questions.
Asexuality (people who are sexually attracted to neither men nor women) www.asexuality.org
The web-based Asexual Visibility and Education Network is one of the world’s largest asexual communities and has 15,000 members.
Gay/Lesbian -
Transgender - did you know that there is an organization based right here in St. Catharines for parents of people who are transgender. If you aren't familiar with the term, need information or help, go to www.transparentcanada.ca and learn.
Sports and Leisure
We can use some help putting this section together. Not being a sports-minded individual, I'd love it if anyone reading this can help fill in below with names or organizations or teams, addresses, websites, etc. in Niagara.
Art - St. Catharines Art Association - Anyone of any level of expertise may join and exhibit their work at the four annual shows the association holds. Regular meetings are held at the St. Catharines Public library and all shows and meetings are wheelchair accessible. For further information contact: Irene Letourneau at: ileturno@becon.org
Basketball
Boating/Sailing
Golf - Rick Hill Services - Rick Hill was the assistant pro and lead pro at two of the major golf courses in Niagara. With 47 years of experience behind him, he will gladly work with seniors and people with disabilities. Balance problems and a weak grip can be overcome and Rick has also worked with people who've had a stroke. Lessons are held at the Niagara Sports Practice Centre on the corner of Eastchester and Highway 55. It is accessible. To find out more check out his website at www.rickhill.ca or e-mail Rick at golf@rickhill.ca or call 905-329-4146.
Rowing
Scuba Diving
Training - Sport by Ability Niagara
Writing
Stress/Destressing
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