Title: Managing Urinary Incontinence
1Managing Urinary Incontinence
- Catherine Van Son, Ph.D., R.N.
2- A journey of a thousand miles begins with one
step. - (or one drop) Lao-tse
There is no one single intervention for managing
urinary incontinence. Management involves
several steps that can lead to the reduction or
elimination of incontinence.
3Urinary Incontinence
- Defined as an involuntary loss of urine in
sufficient amount or frequency to cause social
and/or health problem - Is not a normal consequence of...
- - aging
- - menopause
- - pregnancies
- (although physiological changes such as
those listed may contribute to the
development of incontinence) -
4 UI is not reported because of...
- embarrassment
- lack of information
- a belief it is part of aging
- health care providers dont ask
- a belief there is no effective treatment
- fear of the therapies used to manage the problem
5Psycho-social Impact
- loss of self esteem
- embarrassment
- decrease in ability to maintain independence
- social isolation
- depression
- anxiety
- poor quality of life
- risk of institutionalization
6Self-care behaviors used
- locates or stays near a bathroom when out
- voids more frequently
- wears protective garment
- restricts fluid intake
- does not take certain meds if going out
- restricts social / physical activity
7What is normal?
- daytime
- frequency of no more than once every 2 hours
- nighttime
- 1-2 voidings are considered normal
8Age Related Changes
- decreased bladder capacity (normal is 500-600
ml., older adult capacity may be 250 ml.) - increased residual urine
- increased involuntary bladder contractions
- decreased outlet resistance (females)
- decreased ability to inhibit contractions
- increased outlet resistance (males)
9Forces that Affect the Pelvic Floor
Anatomical
Neurological
Why would the female anatomy increase
incidence of urinary incontinence?
In which ways do the nerves affect the
pelvic floor?
Pelvic Floor
Hormonal
How does estrogen affect the pelvic floor?
Mechanical
What is the impact of pregnancy, constipation,
and/ or prostate enlargement ?
Psychological
How would ones psychological status impact
incontinence?
10Risk factors for UI
- immobility/chronic degenerative disease
- impaired cognition
- medications
- obesity
- diuretics
- fecal impaction, constipation
- low fluid intake
- environmental barriers
- diabetes
- stroke
- estrogen depletion
- smoking
Each of these factors can increase ones risk
for experiencing urinary incontinence. Often
older adults experience more than one risk
factor at any given time.
11Medications can cause...
- frequency
- urgency
- retention
- fecal impaction
- polyuria
- nocturia
- immobility
- sedation
- delirium
12Incontinence History
- Medical History?
- Frequency?
- Sensations?
- Medications?
- Amount?
13Incontinence ScreeningDRIP
NOTE Any one of these conditions can cause acute
onset urinary incontinence and must be evaluated
promptly !
- D - delirium, depression
- R - retention, restricted mobility
- and/or environment
- I - infection, inflammation,
- impaction
- P - pharmaceuticals, polyuria, pain
14Kinds of Urinary Incontinence
- Stress
- Functional
- Environmental
- Urge
- Overflow
- Iatrogenic (caused by hospitalization,
medications, etc.) - Mixed
15Stress Incontinence
- loss of urine that occurs during activities that
increase intra-abdominal pressure - coughing
- sneezing
- laughing
- physical activity (lifting heavy objects)
- caused by pelvic muscular weakness as a result of
- pregnancy
- obesity
- surgery
- medications
- aging (lower estrogen levels)
16Pelvic Floor Muscle Exercises
- Intervention for stress incontinence
- Also known as Kegel exercises
- Requires 2-5 sets of pelvic muscle contractions
done several times each day - Feedback needed so client knows they are doing
them correctly, such as... - vaginal palpation
- biofeedback
- vaginal cones (Look this up what are they and
how are they used?) - Like all exercises success depends on doing them
regularly.
17Functional Incontinence
- physical or psychological impairment that results
in incontinence when the urinary tract is
healthy - causes
- Decreased mobility
- Pain
- Clothing
- Psychological factors
How might these issues cause incontinence when
the urinary tract is healthy?
18Functional Assessment
- ability to put on /take off clothing
- sequence of tasks involved with toileting
- mobility ability to ambulate, use a w/c and/ or
transfer to and from the toilet - access to toilet /device (such as urinals,
bedside commodes, etc.)
19Environmental Incontinence
- psychological message that UI is expected
- chairs are plastic
- beds are protected
- pads are available and applied just in case
- architectural design
- long corridors
- poorly marked bathroom doors
- caregiver attitudes
- Go ahead and go (urinate), Ill clean you up
later. - S/he does that on purpose. (Episodes of
incontinence) - delay in removing wet clothing
20Environmental Assessment
- location/ accessibility of toilets
- signs for bathroom
- call lights/ bells
- adaptive equipment
- cleanliness, safety
21A true story
- Once there was a gentleman with mild
- cognitive impairment who was able to
- toilet independently. However, since
- coming to this new adult day center he
- has been voiding in flower pots and trash
- cans, and wandering into apartments
- next to the adult day center to use
- the bathrooms of tenants who live
- there, which they are not happy
- about.
- What should be done? Think about the
- environment.
22Bathroom Signs
What was puzzling is that he passed by four
bathrooms that were designated for the
participants in the adult day center. Upon
further investigation, it was discovered that
the day center bathroom doors were always closed
due to fire regulations and the signs by the
bathrooms were like the one here on the
right. Could a person with mild dementia
understand that this sign was for the bathroom?
23Solution
- Since he could not tell us we had to make an
educated guess. -
- We enlarged a picture of a toilet, similar to
this one and taped it to each of the day center
bathroom doors. - What do you think happened?
- (You are correct if you think that he gave up
the flower pots for the toilet. The universal
sign for bathrooms may be a barrier to
cognitively impaired individuals.)
Toilet
24Urge Incontinence is
- a loss of urine with an abrupt and strong desire
to void. - Im unable to make it to the bathroom on time.
- caused by an overactive detrusor muscle,
resulting in excessive involuntary bladder
contractions that may be initiated by - cancer (bladder / prostate)
- infection
- spinal or nerve damage
- often found in individuals with
- diabetes, stroke, dementia, Parkinsons disease,
or - multiple sclerosis
25Urge Incontinence Treatment
- Behavioral therapy
- bladder training
- Electrical Stimulation
- biofeedback
- Medications
26Bladder Retraining
- treats urge incontinence
- voiding by the clock
- Freeze Squeeze
- OR
- Sigh and be Dry
- (these actions can help clients get through
initial sensations to void that occur more
frequently with this kind of incontinence. Not
voiding with each urge can retrain the bladder,
so that the need to void is increased to every
two hours and/or when bladder is actually full.)
27Overflow Incontinence
- loss of urine related to the overdistention of
the bladder - frequent or constant dribbling
- may include urge or stress UI
- causes
- loss of bladder muscle tone and/or outlet
obstruction - MS, DM, outflow obstruction (BPH), spinal or
nerve damage - least common, hard to diagnose
- treatment
- review medications
- drainage intermittent, continuous
28When to Refer?
- marked pelvic prolapse
- marked prostate enlargement
- difficulty passing a 14 Fr. catheter
- most cases of overflow
- hematuria
- treatment failures
29Treatment Options for UI
- behavioral techniques
- biofeedback
- scheduled toileting
- exercise
- medication
- surgery
- continence promoting devices
- Pessary (read your textbook or search the
internet to find out how these help women with
incontinence)
30Management of UI is a team effort
- Must involve
- the client
- family
- caregiver(s)
- nursing
- primary care provider
- dietician
- PT/OT/RT/SLP
- management
31Behavioral Interventions
- are non-invasive
- involve caregiver and individual
- measure outcomes
- are inexpensive
- are effective
- are low risk
32Unlocking UI Behavioral Methods
- assessments
- food and fluid changes
- pelvic floor muscle exercises
- bladder retraining
- education
33Bladder (Voiding) Record
- time voiding occurs
- type/ amount of incontinence
- presence of urge sensation
- activity associated with loss of urine
- daily number of pad changes
- intake of dietary irritants
- fluid intake
34Example of Voiding Record
35Physical Exam
- Abdominal/Pelvic/Genitalia/Rectal exam
- Neurological Status
- Dexterity
- Mental Status
- Mobility
36Maintain/Promote Mobility
- assessments by OT / PT / SLP
- use of assistive devices
- walkers, canes
- exercise programs
- proper shoes
- foot care
- uncluttered walkways
37Absorbent Products
- trial and error
- evaluate products for...
- skin irritation
- noise
- comfort
- odor control
- ease of use/ability to change
- absorption
- confidence
38Factors to consider withabsorbent products
- functional disability of client
- type and severity of UI
- gender
- availability of caregivers
- previous treatment programs
- client preference
- skin integrity
- comorbidity
- optimal product for client
- incidence of vaginitis/ bacteriuria
39Mild to Moderate UI
- Serenity (UI pad)
- in one study received highest overall performance
score - Always (menstrual pad)
- Study found that menstrual products
- were to or better than UI products
- and less expensive
- (except for Serenity)
40 Chronic Incontinence
- scheduled toileting
- improved access to toilets
- fluid and diet management
- absorbent garments/ devices
- change clothes when wet
41Food Fluids
- aim for 1500-2000 ml/day
- include jello, soups, popsicles, water-packed
fruits etc. (caution with diabetics) - avoid bladder irritants
- such as caffeine and chocolate
- avoid evening fluids
- treat dependent edema
- elevation during the day
- compression stockings
- decrease sodium intake
-
42Frequent UTIs
- Cranberry juice, 10 oz daily
- must have at least 25 cranberry juice
- Check fluid intake
- Check post-void residual
- Change catheter or remove
43Dementia
- can double the incidence of UI
- inability to dress and/or transfer can increase
incidence 13 times - one study 55 of ambulatory dementia clients
became dry or had a significant improvement in UI
with an individualized scheduled toileting
program (Shelly, J. Flint, A. (1995). Urinary
incontinence associated with dementia. Journal of
the American Geriatric Society, 43(2), 286.)
44UI and Dementia
- utilize habit voiding
- dress in clothing that is easy to remove
- stay with the client and do not distract
- try again in 5 minutes if they say,I just went.
- use language that is understood
- simplify steps involved
- keep bathroom warm and comfortable
45Habit Training
- voiding at predetermined times
- goal to decrease/eliminate number of incontinent
episodes (keep dry) - fixed time intervals
- allows for schedule adjustments
- requires commitment
46Caregiver assessment
- Availability of caregivers?
- Caregivers have the knowledge they need to manage
urinary incontinence? (Schedules, safe transfers,
signs/symptoms of UTI) - Are caregivers willing to help with continence?
- Do caregivers have the equipment they need? (such
as a gait belt for safe transfers)
47Caregiver frustration
- educate
- give lots of positive reinforcement
- seek their input
- problem-solve on weekly basis
- start with one client at a time
- tap into their creativity
48To ponder...
- The bladder is the
- mirror of the soul.
- Chinese proverb
When you gotta go nothing else really matters!
49Urinary Incontinence was prepared by Catherine
Van Son, Ph.D, R.N. for the Older Adult Focus
Project, OHSU School of Nursing.