The Continence of Scipio

Scipio was a Roman general who amongst other achievements defeated Hannibal at the battle of Zama. I have shown the painting by Karel van Mander to medical students over the years to explain the meaning of ‘continence’ – it is one of those things that I know I shouldn’t have done – the connection is tenuous and the meaning obscure; yet, I have not been able to stop myself. Perhaps I have a continence problem myself.

The painting shows Scipio following a battle being offered the wife of one of the defeated soldiers; Scipio, although tempted, manages to restrain himself – utilising his continence.

And this is how I start describing the meaning of continence, the fact that it is in many respects at the centre of our interpersonal relationships. Continence has allowed us to live together, to develop cities and cultures, move from villages to towns, and the converse, loss of continence, represents deterioration.

Continence is often referred to as one of the ‘Geriatric Giants,’ a term defined by the Glaswegian Geriatrician, Sir Bernard Isaacs in the 1970’s to represent some of the fundamental challenges of ageing – confusion, falls and immobility the others.

Yet, despite its importance, continence in the 21^st Century still receives only lip service from society and medicine; this seemingly trivial condition can be the deciding factor in whether a person can live at home independently or require care. Only last week, I discovered the local service is so stretched that care homes have to weigh their residents’ incontinence pads to determine how many they are allowed.

The other end of the spectrum from incontinence is urinary retention – the inability to empty the bladder; in its early stages this can cause Urinary Tract Infections (or UTIs as I have previously written) – the end-stage is complete inability to empty the bladder which results in fatal renal failure if not addressed.

The treatment for this in men is often medicine to relax their prostate – the main factor in determining their continence. When this fails, for men and women, when any drugs that might contribute to urinary retention or other factors are addressed, we are left with the urinary catheter – a rubber tube that passes through the urethra into the bladder and connects to a bag – usually on the person’s leg or their bed.

Catheters are often an accompaniment of physical decline in older people and can represent part of the progressive failure of the individual. Catheters are inevitably associated with recurrent infections, they reduce a person’s mobility, increasing the likelihood of them falling and are associated with increased length of stay in hospital and even an increased chance of death.

Avoiding catheters is one of the goals of all doctors, particularly those looking after older people.

Continence needs to move from the shadows into the centre of the debate about older people and society, if we can support people better with their continence we can hope to maintain more people living independently, better able to contribute to the society around them and enjoy the benefits of participation and co-production of life.