Nursing Center - Journal Issue

"URINARY INCONTINENCE (UI) is a natural way of life. Most older adults have this problem, and they can't do much about it." "Women normally have trouble with incontinence after having children and as they age." "Because older women with incontinence have no realistic hope of correcting it, they should rely on incontinence products."

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Figure. No caption available.

None of these statements is correct. UIisn't an inevitable consequence of aging, and when it does occur, it can be effectively treated. Yet many older adults and even some healthcare professionals continue to hold outdated attitudes about a stubborn but treatable problem that can undermine a patient's health and quality of life.

This article encourages nurses to "rethink incontinence" based on current research and best practices. Although it focuses on practical and evidence-based solutions for incontinence in older women in long-term-care (LTC) facilities, much of the information applies to other patient groups as well.

Widespread problem

UI is defined as an involuntary loss of urine that causes a problem for the person who has it. Although incontinence is more common in older adults, it also affects younger people. Nationwide consumer research found that one in four women over age 18 experiences episodes of involuntary urine leakage.1

According to the Wound, Ostomy and Continence Nurses Society (WOCN), 30% of home-bound older adults are incontinent, and UI contributes significantly to their home-bound status.2 More than half of all residents in LTC facilities are incontinent, and incontinence is the second leading cause of institutionalization.1

Many people use incontinence products and learn to live with the problem, never seeking advice from a healthcare professional because they're embarrassed or ashamed. Incontinence leads to isolation when people become afraid to go out or venture far from bathroom facilities. It can cast a shadow on everyday activities, such as selecting clothes, food, and drinks; making travel plans; having sexual relationships; or forging friendships. UI is also associated with various physical problems such as skin irritation, yeast infections, and odors.

Figure. Organs of ur... - Click to enlarge in new window

Figure. Organs of urine excretion up close

Sorting out the types

Knowing which of several types of UI a person is experiencing will help to narrow the treatment options.

* Urge incontinence, also known as overactive bladder or spastic bladder, is probably the most common type of incontinence in older LTC residents.3 (See Organs of excretion up close.) The National Association for Continence (NAFC) estimates that 12.2 million people have urge incontinence.1 Defined as the loss of urine as soon as the urge is felt, it's characterized by urgency, frequency, and nocturia. The resident feels the need to void but can't stop voiding long enough to get to the toilet. It's caused by an involuntary contraction of the detrusor muscle (smooth muscle of the bladder wall) causing urine leakage.4

* Stress incontinence, common in older women, is the loss of a small amount of urine with physical activity, such as coughing, sneezing, laughing, climbing stairs, or lifting. According to the NAFC, 15 million women in the United States are affected by stress incontinence.3 It's considered a urine storage problem due to sphincter incompetence, not bladder distension. Urine leaks because of increased intra-abdominal pressure.4

* Mixed incontinence, a combination of both stress and urge incontinence, is most common in older women.4

* For patients with overflow incontinence, also called incomplete bladder emptying, the bladder never feels completely empty. The patient usually loses only small amounts of urine during the day and night and often gets up at night to urinate. Impaired detrusor contractility and/or bladder outlet obstruction causes this type of incontinence. Signs and symptoms include a weak stream, dribbling of urine, hesitancy, incomplete voiding, dysuria, or nocturia.4

* Functional incontinence, the loss of bladder control due to a functional deficit instead of a structural problem, is sometimes classified into three groups. Patients with mobility and access deficits are confined to a wheelchair or need to ambulate with a device such as a walker or brace. This person has a limited ability to get to the toilet. Patients may also be hindered by deficits in dexterity due to weakness from such conditions as a stroke or peripheral neuropathy. Incontinent patients with altered mental status and motivation may lack the initiative to get up and go to the bathroom. Conditions such as morbid obesity or depression can affect motivation. Someone with altered mental status may not understand the toileting process.5

* Temporary incontinence comes and goes with specific conditions, such as severe constipation or urinary or vaginal infections. It can also be caused by certain medications, including diuretics, sedative-hypnotics, muscle relaxants, opioids, antihistamines, antidepressants, antipsychotics, or calcium channel blockers.4

Follow the guidelines

Dowling-Castronovo and Bradway's "Nursing Standard of Practice Protocol: UI in Older Adults Admitted to Acute Care" recommends parameters of assessment, nursing care strategies, and follow-up monitoring.6 They advocate documenting the presence or absence of UI for all patients on admission and throughout hospital stay. These general principles apply to prevention and management of all forms of UI:

* finding and treating the causes

* using successful prehospital management strategies for established UI

* avoiding medications that contribute to UI

* avoiding indwelling urinary catheters

* providing usual undergarments in expectation of continence

* preventing skin breakdown.6

These guidelines provide strategies for specific problems related to stress, urge, overflow, and functional incontinence. They also recommend providing follow-up monitoring withdischarge teaching for the patient orcaregiver as well as incorporating quality improvement into the hospital's program.6

These guidelines are as important for residents in LTC facilities as for patients in acute care facilities. According to incontinence guidelines issued in June 2005 by the Centers for Medicare and Medicare Services, a resident who's incontinent of bladder should receive appropriate treatment and services to prevent urinary tract infections (UTIs) and to restore as much normal bladder function as possible.7

This regulation is meant to ensure that a resident who has UI is identified, assessed, and given appropriate treatment and services to achieve or maintain as much normal urine function as possible.7

To meet this goal, facility staff must ensure that assessments are timely and appropriate. Interventions must be defined by the facility's policies and procedures, implemented on an individual basis, and monitored, evaluated, and revised as needed.7

The WOCN has developed "Incontinence-Associated Dermatitis (IAD): Best Practice for Clinicians," which addresses assessing, treating, and monitoring the patient. It discusses skin integrity, self-concept, changes in self-esteem, body image, role performance and personal identity, possible isolation related to odor and embarrassment, and knowledge deficits. Skin integrity issues, including actual or potential problems, are also covered in this document.8

Performing an assessment

The nurse thoroughly assesses each resident by obtaining a health history from the resident, family, or medical record and performing a physical assessment.

The health history should address UTIs, cystitis, or bladder surgeries. Aneurologic history may provide valuable information about such disorders as a spinal cord injury, Alzheimer disease, seizure disorders, traumatic brain injury, Parkinson disease, or stroke.

A UI history should be obtained from the resident if possible.7,9 (See Asking the right questions.) A voiding diary can help gather important information, including continent andincontinent episodes both day and night. It can be as simple as listing times when the resident voids or iswet. A more detailed diary can include amounts voided and leaked, amounts of fluid consumed, and activity when leaking occurred. Diaries are usually kept for 2 to 7days to get an accurate picture ofthe resident's pattern.10

Review the resident's list of prescription and over-the-counter medications because some medications may magnify existing problems or contribute to incontinence; for example, by causing urethral relaxation.11 (See On alert for medication problems.)

The physical assessment should focus on the abdomen to detect tenderness, pain, or masses. Assess women for genitourinary abnormalities, such as vaginal atrophy, masses, decreased muscle tone, and perineal discharge. Perform a digital rectal exam to assess sphincter tone and identify fecal impaction or masses.12

In the general exam, assess for cognitive impairments, neurologic abnormalities, mobility problems, and peripheral edema.12

Diagnostic studies

Lab and radiology testing are needed to complete the assessment.

* Urine studies such as urinalysis can identify the presence of bacteria, protein, red or white blood cells, and glucose. Results can help diagnose such disorders as UTI and diabetes mellitus.

* Blood tests. Blood urea nitrogen and creatinine levels can help determine dehydration or renal dysfunction.

* Radiology studies may include X-rays of the kidneys, ureters, and bladder to assess for abnormalities, such as calculi. An I.V. pyelogram and a contrast cystogram can show structural defects. A voiding cystourethrogram can demonstrate functional abnormalities. Urodynamic studies can provide information such as bladder capacity and sensation, contractility, and ability to empty.

After the type of incontinence is determined, the nurse can develop a patient-care plan that will help the resident become more or completely continent.

Planning interventions

Try the easiest interventions first, especially for acute incontinence. When incontinence develops quickly, it's likely to respond to a relatively simple treatment. For example, successful treatment of a UTI or constipation may correct UI.

Suppose a resident can't manage in a small bathroom because of a full-length leg cast. Use a bedside commode. If the resident's blood glucose levels are too high, make recommendations to get them under control through diet or medication adjustment. If the resident has a functional impairment, suggest using different fasteners on pants, such as zippers or hook-and-loop fasteners instead of buttons.

Another simple intervention is a change in diet. Eliminating bladder irritants such as caffeinated or citrus beverages can decrease the need for frequent voiding.

Drinking fluids later in the evening can cause nocturia, which can cause problems if the resident is a sound sleeper or can't get up to void. Controlling the amount of fluid a resident drinks during the day can help prevent nocturia. An average adult should drink about 32 to 64 oz (about 1 to 2 L) throughout the day.13 Drinking significantly more or less can contribute to nocturia. Some people think that the less they drink, the more likely they are to stay continent at night. In fact, too little fluid intake can lead to a concentration of waste in the urine, which can irritate the bladder.14

Behavioral interventions

Besides being noninvasive and free of adverse reactions, behavior techniques don't limit treatment options. They can be used as a first-line treatment to help control incontinence, especially urge incontinence. These aren't only behavioral techniques but also lifestyle changes that need to be practiced daily.

Bladder training (sometimes called bladder retraining), which can be used alone or in combination with other therapies, involves learning to delay urination after the urge to "go" is felt. The person tries to hold the urge for 10 minutes and then lengthens the time between trips to the bathroom until the goal of going only every 2 to 4 hours is met.

A variation of bladder training is the scheduled toileting plan. With this intervention, the person goes to the bathroom according to the clock, usually every 2 to 4 hours, rather than waiting for an urge. The plan may need to start out with more frequent trips to the bathroom and then build up to the goal.

Programs depending on staff assistance for success include the prompted voiding program, a behavioral technique appropriate for use with dependent or cognitively impaired residents. The goal is for the resident to receive assistance from the caregiver before an episode of incontinence occurs. Regular monitoring with praise and positive feedback is performed at the resident's scheduled times. For example, prompted times may be the first thing in the morning, before meals, before activities, and right before bedtime. This program is effective for residents with any type of incontinence and those with cognitive impairment who can say their name and reliably point to one of two objects.7

Another type of behavior intervention is the pelvic floor muscle exercise, also known as the Kegel exercise. This exercise strengthens the urinary sphincter and pelvic floor muscles. The person needs to learn to squeeze the muscles used to stop urination and hold those muscles for a count of three and then repeat. This program requires the resident to strengthen the periurethral and pelvic muscles 30 to 80 times a day for at least 6 weeks for positive results. This exercise seems to work better for women who have stress incontinence.15

Biofeedback, another type of behavioral intervention, may be most effective for stress incontinence. This electronic or mechanical method records the progress of the strengthening exercises. A sensor is inserted into the vagina or rectum to detect electric signals as the muscles are contracted and relaxed. The computer records the muscle activity to determine if the correct muscles are being moved.16

Other interventions

Devices such as weighted vaginal cones can be used with or without biofeedback. These cones are inserted into the vagina to help strengthen the muscles as the resident voluntarily contracts the muscles around the cones.

Another vaginal device is the pessary, a stiff ring that's inserted into the vagina where it presses against the wall of the vagina and the nearby urethra. The pressure helps reposition the urethra, leading to less stress incontinence.17

Urethral occlusion devices are inserted into the urethra or placed over the urethral muscle to prevent urine leakage. They should be removed after several hours or after each void. These devices are helpful for activity-induced incontinence.16

Neuromodulation therapy, which involves stimulation of nerves to the bladder, can be used to treat urge incontinence. The FDA has approved an internal stimulator. This therapy is expensive and requires minor surgery to place the device.17

Several types of electrical stimulation are available. In an office-based procedure, a needle is inserted into the nerve to send electrical impulses to help reduce the person's need to frequently rush to the bathroom. It must be done one to three times a week for 6 to 8 weeks. The sacral nerve stimulator is discussed under surgical options.

Acupuncture is a promising alternative therapy. Although one study reported a 77% improvement rate, more study is needed to determine its effectiveness.16

A device for extracorporeal magnetic resonance therapy has been approved by the FDA for stress incontinence. To use this therapy, the person sits on a chair containing a magnetic device, and the magnetic field induces electrical depolarization of the targeted nerves and muscles. One study showed a 77% improvement after 8 weeks of therapy.16

People with overflow incontinence can use an intermittent or indwelling urinary catheter. Clean intermittent catheterization, which provides regular and complete bladder emptying, helps prevent UTIs and increased pressure from outlet obstruction. Self-catheterization is preferred if the resident is able to perform it. An indwelling catheter or suprapubic catheter can be considered for those who can't perform the procedure.

Indwelling catheters are a significant cause of UTIs; untreated UTIs may lead to urosepsis and even death. Other problems with catheters include encrustation of the catheter, bladder spasms, bladder stones, periurethral abscess, renal damage, and urethral erosion. Catheters should beused only if other options aren't effective or for the short-term until a different treatment can be implemented.16

Medications may be indicated only if simple interventions haven't worked. Some urologists believe medications can increase continence by 50%. (See Sorting out medications prescribed for UI.)

Surgical options

Surgery cures stress incontinence better than any other treatment. If other treatments such as pelvic floor muscle exercises aren't effective, then surgery may be the best option. Surgery is performed less often for urge incontinence, and the results are not as good.18

Surgical procedures are divided into two categories: sling procedures and bladder suspension procedures. Sling procedures, used to treat stress incontinence, use strips of body tissue or synthetic material to create a sling around the bladder neck and urethra to help keep the urethra closed. These procedures are usually highly effective, with only a low risk of complications. Examples include tension-free slings. Tissue holds the synthetic strip of mesh in place until scar tissue forms to hold the mesh in place. Adjustable slings being trialed are placed surgically and then adjusted as needed after the person is awake. Conventional slings still in use include a sling (synthetic or the patient's own tissue) that's attached to the pelvic tissue or abdominal wall to obtain the correct tension. In the bladder neck suspension procedure, the surgeon sutures the tissue near the bladder neck and ligament near the pubic bone to reinforce the urethra and bladder neck to provide support and prevent sagging.18

Bulking agents are another form of treatment, especially for stress incontinence. Injected periurethrally, they increase tissue bulk and resistance to urine outflow. The agent used is a liquid that solidifies into a spongy material to bulk the urethral wall. Some agents used are collagen, a component of bones and teeth; carbon-coated zirconium beads; and silicone implants. Because collagen can cause an allergic reaction, the patient will need a skin test before it's used. This procedure is usually done in the healthcare provider's office. These agents may lose their effectiveness over time and repeat procedures may be needed.17

Transurethral collagen denaturation (the Ranessa procedure), an outpatient procedure, is also used for stress incontinence. Small needles deliver radiofrequency energy, which denatures surrounding collagen and tightens the tissue.18

Surgery for urge or overactive bladder includes the sacral nerve stimulator, which is surgically implanted under the skin in the upper buttocks area. The wires connected to it send electrical impulses to the sacral nerve, helping to reduce incontinence. The risks of this procedure include infection or the movement of the device over time.13

Bladder augmentation is a procedure used to increase the size of the bladder. This major surgery requires hospitalization and a lengthy recovery period.

Overflow incontinence due to outlet obstruction can be corrected with surgery.

Future management options for UI may include an inflatable free-floating balloon and muscle-derived stem cell injections into the periurethral tissue.20

Providing support and education

Regardless of practice area, a nurse can help those with UI manage their condition and avoid complications. Teach residents and their caregivers to clean urine from the skin with cleaners that prevent drying. Apply skin protection such as sealants, moisteners, or barrier products. Manage skin problems quickly to prevent the condition from worsening. Apply skin barrier powders to denuded skin and antifungal preparations to skin showing signs and symptoms of candidiasis.21

Address any self-concept changes noted. Encourage residents to express their concerns and feelings about incontinence and any perceived effects on lifestyle. Provide realistic and sincere feedback.

Assist residents through the intervention phase, providing positive feedback. If incontinence isn't totally corrected, assist the resident in choosing the most appropriate absorbent product. If odor is an issue, suggest ways to manage incontinence when away from home. Some odor-controlling measures that may help include hygiene, such as washing thoroughly after an incontinence episode. Odor-reducing products should be used instead of perfumes that cover up smells. The bed sheets and clothing should be washed frequently, and air fresheners should contain odor eliminators. The resident can also take deodorizing tablets (for example, chlorophyllin) or vitamin C, with the healthcare provider's approval. Consuming enough fluids, drinking cranberry juice, and foregoing foods such as coffee or asparagus can lessen odors. Detecting and treating a UTI can also help decrease odors.22

Educate residents about the normal voiding process, signs and symptoms of UTIs, and the cause of their incontinence. Residents need to understand how the intervention chosen will help them manage their incontinence.16

Not all UI can be totally corrected. If a resident is less incontinent after trying some of these interventions, you can claim success. As nurses, we should educate patients and families about available options to lessen or eliminate UI.

Asking the right questions

Ask the resident or the family these questions:

* When did you first notice the incontinence?

* If you use pads, are they soaked? How many pads and what type of pads do you use?

* Does anything such as coughing or sneezing cause an episode of incontinence?

* Have you tried any treatments? Which ones?

* What's your pattern of voiding, including frequency, amount, and day or night time voiding?

* What do you think is causing your incontinence?

* When and what types of beverages do you normally drink?

* Do you have physical problems (such as impaired mobility or manual dexterity, poor muscle strength, decreased vision, pain with mobility, and need for assistance devices such as a walker or raised toilet seat) that cause problems getting to the bathroom?

* Do any environmental factors contribute to incontinence? For example, is the lighting to the bathroom adequate both day and night? Can you reach a call bell? Are you afraid of falling? Is the pathway to the bathroom clear of obstructions? Are the bathroom facilities, such as a toilet seat that's low or an inadequate size, causing problems for you?

On alert for medication problems

During medication reconciliation, watch for these medications that can cause or exacerbate incontinence.

* Alpha-adrenergic receptor blockers such as prazosin can decrease sphincter tone and prevent tight closure of the sphincter muscles.

* Anticholinergics such as atropine, certain antidepressants (amitriptyline, desipramine, nortriptyline), and antihistamines (diphenhydramine), can cause urinary retention with urinary frequency and overflow. Because they cause voiding in small but frequent amounts, the resident may not have enough time to get to the bathroom.

* Calcium channel blockers such as nifedipine can reduce the bladder's ability to contract, leading to overflow incontinence.

* Diuretics such as furosemide may make a mild problem worse. An increase in urine production can lead to frequency and urgency.

* Sedative-hypnotics such as diazepam can lead to confusion and prevent or delay the urge to void.