Urinary Urinary IncontinenceIncontinence

Barbara Dale RN CWON CHHN Barbara Dale RN CWON CHHN

Quality Home HealthQuality Home Health

September 25, 2006September 25, 2006

Urinary IncontinenceUrinary Incontinence

• Urinary incontinence is defined as the Urinary incontinence is defined as the involuntary leakage of urine from the involuntary leakage of urine from the bladder bladder

• Urinary Incontinence affects 17 million Urinary Incontinence affects 17 million people in the United States every year people in the United States every year with 85% of them womenwith 85% of them women

• One in three persons over age 60 are One in three persons over age 60 are affected by urinary incontinenceaffected by urinary incontinence

• 38% of women over 60 are affected38% of women over 60 are affected• 87% of all forms of incontinence can be 87% of all forms of incontinence can be

effectively managedeffectively managedhttp://kidney.niddk.nih.gov/kudiseases/pubs/kustats/index.htm

CausesCauses• Hormonal changesHormonal changes

• Weakened pelvic muscles r/t Weakened pelvic muscles r/t childbirthchildbirth

• Prostate disorders/surgeryProstate disorders/surgery• Pelvic traumaPelvic trauma

• Spinal cord damageSpinal cord damage• Caffeine Caffeine

• MedicationsMedications• Neurological/Cognitive disorders such Neurological/Cognitive disorders such

as MS & Alzeimer’sas MS & Alzeimer’s

Urinary incontinence is Urinary incontinence is notnot a a natural part of aging.natural part of aging.

It can happen at any age, and can be caused It can happen at any age, and can be caused by many physical conditions. Many causes by many physical conditions. Many causes of incontinence are temporary and can be of incontinence are temporary and can be

managed with simple treatment. Some managed with simple treatment. Some causes of temporary incontinence are:causes of temporary incontinence are:

– Urinary tract infection Urinary tract infection – Vaginal infection or irritation Vaginal infection or irritation

– Constipation Constipation – Effects of medicine Effects of medicine

Voiding PhysiologyVoiding Physiology

• Normal voiding requires coordination Normal voiding requires coordination between multiple structures and between multiple structures and nerve pathways. nerve pathways.

• Key structures include the brain, Key structures include the brain, brainstem, spinal cord, bladder, and brainstem, spinal cord, bladder, and urethral sphincter mechanism.urethral sphincter mechanism.

The Brain and Social The Brain and Social ContinenceContinence

• The brain(cerebral cortex) provides overall The brain(cerebral cortex) provides overall control and direction of bladder function.control and direction of bladder function.– The Detrusor area in the cerebral cortex controls The Detrusor area in the cerebral cortex controls

bladder function by directing the micturition bladder function by directing the micturition centers to initiate or delay voiding depending on centers to initiate or delay voiding depending on the social situation. This is called social continence the social situation. This is called social continence

– Any disruption in the cerebrocortical function can Any disruption in the cerebrocortical function can cause or contribute to incontinence. cause or contribute to incontinence.

– CVA is a common cause of incontinence because CVA is a common cause of incontinence because the two most common arteries involved in CVA are the two most common arteries involved in CVA are the same two that supply the detrusor area of the the same two that supply the detrusor area of the brain.brain.

BrainstemBrainstem

• The pontine micturition center in the The pontine micturition center in the brainstem provides for automatic brainstem provides for automatic coordinated voiding. Meaning the urethra coordinated voiding. Meaning the urethra opens before the bladder contracts.opens before the bladder contracts.

• The pons also holds the micturition ‘reflex’ The pons also holds the micturition ‘reflex’ center which allows the bladder to empty center which allows the bladder to empty when reaching a certain fullness when reaching a certain fullness irregardless of social situation. Especially irregardless of social situation. Especially important for spinal cord patients.important for spinal cord patients.

Spinal Cord PathwaysSpinal Cord Pathways

• Parasympathetic-comes off at S2-S4 Parasympathetic-comes off at S2-S4 and cause the bladder to contract and and cause the bladder to contract and the urethra to relax. Parasympathetic the urethra to relax. Parasympathetic

stimulation initiates voiding. stimulation initiates voiding.

• Sympathetic pathways come off at T-Sympathetic pathways come off at T-10 L2 that cause bladder neck to 10 L2 that cause bladder neck to

tighten and also contribute to bladder tighten and also contribute to bladder relaxation. Sympathetic stimulation relaxation. Sympathetic stimulation

contributes to urine storage and contributes to urine storage and promotes continence. promotes continence.

Bladder, Urethra, and Sphincters

Types of IncontinenceTypes of Incontinence

• StressStress

• UrgeUrge

• Mixed stress/urgeMixed stress/urge

• Overflow (retention)Overflow (retention)

People with urge incontinence lose urine as People with urge incontinence lose urine as soon as they feel a strong need to go to the soon as they feel a strong need to go to the bathroom.bathroom.(AKA Overactive bladder)(AKA Overactive bladder)If you have urge incontinence you may If you have urge incontinence you may leak urine:leak urine:

• When you can't get to the bathroom quickly When you can't get to the bathroom quickly enough enough

• When you drink even a small amount of When you drink even a small amount of liquid, or when you hear or touch running liquid, or when you hear or touch running water water

• You may go to the bathroom very often; for You may go to the bathroom very often; for example, every two hours during the day example, every two hours during the day and night and night

• You may even wet the bed You may even wet the bed

Urge Incontinence Causes/Risk Urge Incontinence Causes/Risk FactorsFactors

• Aging is a Aging is a riskrisk factor simply due to factor simply due to reduced bladder capacity, delayed reduced bladder capacity, delayed recognition of bladder filling resulting recognition of bladder filling resulting in reduced “response” time. in reduced “response” time.

• Bladder irritants, neurological Bladder irritants, neurological lesions, stones, cancer, obstructed lesions, stones, cancer, obstructed flow. flow.

• IdiopathicIdiopathic

People with stress incontinence lose urine People with stress incontinence lose urine when they exercise or move in a certain when they exercise or move in a certain way. If you have stress incontinence, you way. If you have stress incontinence, you may leak urine:may leak urine:

• When you sneeze, cough, or laugh When you sneeze, cough, or laugh

• When you get up from a chair or out of When you get up from a chair or out of bed bed

• When you walk or do other exercise When you walk or do other exercise

• You may also go to the bathroom often You may also go to the bathroom often during the day to avoid accidents. during the day to avoid accidents.

People with overflow incontinence may feel People with overflow incontinence may feel that they never completely empty their that they never completely empty their bladder. If you have overflow incontinence, bladder. If you have overflow incontinence, you may:you may:

• Often lose small amounts of urine during Often lose small amounts of urine during the day and night the day and night

• Get up often during the night to go to the Get up often during the night to go to the bathroom bathroom

• Often feel as if you have to empty your Often feel as if you have to empty your bladder but can't bladder but can't

• Pass only a small amount of urine but feel Pass only a small amount of urine but feel as if your bladder is still partly full as if your bladder is still partly full

• Spend a long time at the toilet, but produce Spend a long time at the toilet, but produce only a weak, dribbling stream of urine only a weak, dribbling stream of urine

• People with overflow incontinence do not feel the urge to People with overflow incontinence do not feel the urge to urinate. The bladder never empties normally and remains at urinate. The bladder never empties normally and remains at

least partially full; small amounts of urine are leaked on a least partially full; small amounts of urine are leaked on a nearly continuous basis. Weak bladder muscles -- caused by nearly continuous basis. Weak bladder muscles -- caused by

nerve damage from diabetes or other diseases -- or a blocked nerve damage from diabetes or other diseases -- or a blocked urethra can be responsible for overflow incontinence.urethra can be responsible for overflow incontinence.

• Overflow incontinence most frequently appears in older men in Overflow incontinence most frequently appears in older men in whom an enlarged prostate hinders the flow of urine; urinary whom an enlarged prostate hinders the flow of urine; urinary

stones or tumors also may block the urethra. Overflow stones or tumors also may block the urethra. Overflow incontinence is rare in women, although sometimes it is caused incontinence is rare in women, although sometimes it is caused

by fibroid or ovarian tumors. Spinal cord injuries or nervous by fibroid or ovarian tumors. Spinal cord injuries or nervous system disorders are additional causes of overflow system disorders are additional causes of overflow

incontinence.incontinence.

Some of the symptoms of overflow incontinence are:Some of the symptoms of overflow incontinence are:

Feeling as though the bladder is never completely empty.Feeling as though the bladder is never completely empty.Feeling the urge to urinate, but not being able to.Feeling the urge to urinate, but not being able to.

Passing a dribbling stream of urine, even after spending a long Passing a dribbling stream of urine, even after spending a long time at the toilet.time at the toilet.

Frequently getting up at night to urinate.Frequently getting up at night to urinate.Although some people with overflow incontinence never have Although some people with overflow incontinence never have

the feeling of a full bladder, they may leak urine day and night.the feeling of a full bladder, they may leak urine day and night.

Overflow Incontinence Overflow Incontinence CausesCauses

Functional IncontinenceFunctional Incontinence

• Diagnosis: Usually one of elimination. Diagnosis: Usually one of elimination. Patient voids large amounts at regular Patient voids large amounts at regular intervals. intervals.

• Incontinence in patient with normal voiding Incontinence in patient with normal voiding patterns and normal bladder function, patterns and normal bladder function, usually related to cognitive status, usually related to cognitive status, motivation, and/or mobility issues.motivation, and/or mobility issues.

• Cortex doesn’t process the signals from the Cortex doesn’t process the signals from the bladder. An automatic voiding when bladder bladder. An automatic voiding when bladder is full. No social continence.is full. No social continence.

• Tx: prompted or timed voiding. Containment Tx: prompted or timed voiding. Containment products and skin care.products and skin care.

TreatmentsTreatments

• Pelvic Muscle RehabilitationPelvic Muscle Rehabilitation

• Behavioral therapyBehavioral therapy

• Pharmacological TherapiesPharmacological Therapies

• PessaryPessary

• Surgical TherapiesSurgical Therapies

Assessment and EvaluationAssessment and Evaluation

•MD/UNP/WOCNMD/UNP/WOCN

•DIAPPERSDIAPPERS

•Bladder DiaryBladder Diary

DIAPPERSDIAPPERS

D-DeliriumD-Delirium

I- InfectionI- Infection

A-Atrophic urethritis/vaginitisA-Atrophic urethritis/vaginitis

P-PharmaceuticalsP-Pharmaceuticals

P-Psychological StatusP-Psychological Status

E-Endocrine changesE-Endocrine changes

R-Restricted mobilityR-Restricted mobility

S-Stool ImpactionS-Stool Impaction

Pelvic Muscle RehabilitationPelvic Muscle Rehabilitation

•KegelsKegels

•Vaginal weightsVaginal weights

•BiofeedbackBiofeedback

• The first step is to find the right muscles. Imagine The first step is to find the right muscles. Imagine that you are sitting on a marble and want to pick that you are sitting on a marble and want to pick up the marble with your vagina. Imagine “pulling" up the marble with your vagina. Imagine “pulling" the marble up into your vagina.the marble up into your vagina.

• Try not to squeeze other muscles at the same Try not to squeeze other muscles at the same time. Be careful not to tighten your stomach, legs, time. Be careful not to tighten your stomach, legs, or buttocks. Squeezing the wrong muscles can put or buttocks. Squeezing the wrong muscles can put more pressure on your bladder control muscles. more pressure on your bladder control muscles. Just squeeze the pelvic muscles. Don't hold your Just squeeze the pelvic muscles. Don't hold your breath. Do not practice while urinating.breath. Do not practice while urinating.

Kegel ExercisesKegel Exercises

• Repeat, but don't overdo it. At first, find a quiet Repeat, but don't overdo it. At first, find a quiet spot to practice—your bathroom or bedroom—so spot to practice—your bathroom or bedroom—so you can concentrate. Pull in the pelvic muscles you can concentrate. Pull in the pelvic muscles and hold for a count of 3. Then relax for a count of and hold for a count of 3. Then relax for a count of 3. Work up to 3 sets of 10 repeats. Start doing 3. Work up to 3 sets of 10 repeats. Start doing your pelvic muscle exercises lying down. This is your pelvic muscle exercises lying down. This is the easiest position to do them because the the easiest position to do them because the muscles do not need to work against gravity. muscles do not need to work against gravity. When your muscles get stronger, do your When your muscles get stronger, do your exercises sitting or standing. Working against exercises sitting or standing. Working against gravity is like adding more weight.gravity is like adding more weight.

• Be patient. Don't give up. It takes just 2-5 minutes Be patient. Don't give up. It takes just 2-5 minutes a day. You may not feel your bladder control a day. You may not feel your bladder control improve for 3 to 6 weeks. Still, most people do improve for 3 to 6 weeks. Still, most people do notice an improvement after a few weeks.notice an improvement after a few weeks.

Behavioral TherapiesBehavioral Therapies

• Scheduled toiletingScheduled toileting

• Prompted voidingPrompted voiding

• Improved access to toiletsImproved access to toilets

• Managing fluids and dietManaging fluids and diet

• Disposable absorbent undergarmentsDisposable absorbent undergarments

Bladder TrainingBladder Training

• Bladder training has many variations Bladder training has many variations but generally consists of three but generally consists of three primary components: primary components: – EducationEducation– Scheduled voidingScheduled voiding– Positive reinforcementPositive reinforcement

• The education program usually combines a The education program usually combines a written, visual, and verbal instruction package written, visual, and verbal instruction package that addresses the physiology and that addresses the physiology and pathophysiology of the lower urinary tract. The pathophysiology of the lower urinary tract. The voiding schedule incorporates a progressively voiding schedule incorporates a progressively increased interval between mandatory voidings increased interval between mandatory voidings with concomitant distraction or relaxation with concomitant distraction or relaxation techniques. The person is taught to delay techniques. The person is taught to delay voiding consciously. If the patient is unable to voiding consciously. If the patient is unable to delay voiding between schedules, one delay voiding between schedules, one approach is to adjust this schedule and start approach is to adjust this schedule and start the timing from the last void. Another option is the timing from the last void. Another option is to keep the prearranged schedule and to keep the prearranged schedule and disregard the unscheduled void between disregard the unscheduled void between schedules. Positive reinforcement is provided. A schedules. Positive reinforcement is provided. A bladder retraining program requires the bladder retraining program requires the participant to resist or inhibit the sensation of participant to resist or inhibit the sensation of urgency, to postpone voiding, and to urinate urgency, to postpone voiding, and to urinate according to a timetable rather than according according to a timetable rather than according to the urge to void. This form of training has to the urge to void. This form of training has been used to manage UI due to bladder been used to manage UI due to bladder instability. instability.

Habit TrainingHabit Training

• Habit training or timed voiding is scheduled Habit training or timed voiding is scheduled toileting on a planned basis. The goal is to toileting on a planned basis. The goal is to keep the person dry by telling keep the person dry by telling them/assisting them to void at regular them/assisting them to void at regular intervals. Attempts are made to match the intervals. Attempts are made to match the voiding intervals to the person's natural voiding intervals to the person's natural voiding schedule. Unlike bladder retraining, voiding schedule. Unlike bladder retraining, there is no systematic effort to motivate the there is no systematic effort to motivate the patient to delay voiding and resist urge.patient to delay voiding and resist urge.

Timed Voiding ManagementTimed Voiding Management

• Goal: To keep patient dry(at least during Goal: To keep patient dry(at least during waking hours) by toileting him/her often waking hours) by toileting him/her often enough to prevent incontinence. enough to prevent incontinence.

• Guidelines: Determine patients usual Guidelines: Determine patients usual voiding frequency by having caregiver voiding frequency by having caregiver complete bladder chart/diary. Instruct complete bladder chart/diary. Instruct caregiver to take patient to bathroom caregiver to take patient to bathroom according to schedule and “cue” to void. according to schedule and “cue” to void. Alternative in LTC environment that may Alternative in LTC environment that may be more effective is ADL based schedule: be more effective is ADL based schedule: upon arising, after lunch, before supper, upon arising, after lunch, before supper, and at bedtime. and at bedtime.

Trouble shooting Timed Trouble shooting Timed voidingvoiding• Pt who is voiding small amounts needs Pt who is voiding small amounts needs

to be evaluated for additional factors to be evaluated for additional factors contributing to bladder dysfunction contributing to bladder dysfunction and incontinence such as infection, and incontinence such as infection, impaction, retention, bladder irritants. impaction, retention, bladder irritants. If reversible factors and retention have If reversible factors and retention have been ruled out, consult MD for possible been ruled out, consult MD for possible trial of anticholinergics. trial of anticholinergics.

Prompted VoidingPrompted VoidingPrompted voiding has been shown to be Prompted voiding has been shown to be

effective in dependent or cognitively effective in dependent or cognitively impaired nursing home incontinent patients. impaired nursing home incontinent patients. As a supplement to habit training, prompted As a supplement to habit training, prompted voiding attempts to teach the incontinent voiding attempts to teach the incontinent person to discriminate their incontinence person to discriminate their incontinence status and to request toileting assistance status and to request toileting assistance from caregivers. There are three major from caregivers. There are three major elements to prompted voiding: Monitoring. elements to prompted voiding: Monitoring. The person is checked by caregivers on a The person is checked by caregivers on a regular basis and asked to report verbally if regular basis and asked to report verbally if wet or dry. Prompting. The person is asked wet or dry. Prompting. The person is asked (prompted) to try to use the toilet. Praising. (prompted) to try to use the toilet. Praising. The person is praised for maintaining The person is praised for maintaining continence and for attempting to toilet. continence and for attempting to toilet.

PharmacologicalPharmacological

Work on parasympathetic nervous Work on parasympathetic nervous systemsystem

• CholinergicsCholinergics– Urecholine promotes bladder Urecholine promotes bladder

contractility/reduce retentioncontractility/reduce retention

• AnticholinergicsAnticholinergics– Ditropan reduces sensory urgency and Ditropan reduces sensory urgency and

bladder contractilitybladder contractility

Medications that affect Medications that affect ContinenceContinence

• Sedatives (hypnotics, alcohol)Sedatives (hypnotics, alcohol)• DiureticsDiuretics• Anticholinergic drugs (antipsychotics, Anticholinergic drugs (antipsychotics,

antidepressants, antihistamines, anti-antidepressants, antihistamines, anti-Parkinson’s, antiarrhythmics, Parkinson’s, antiarrhythmics, antispasmodics, antidiarrheals)antispasmodics, antidiarrheals)

• Antihypertensive drugs that relax smooth Antihypertensive drugs that relax smooth muscle including the bladder neck muscle including the bladder neck (catapres, aldomet, minipress)(catapres, aldomet, minipress)

• Adrenergics-decongestants that tighten Adrenergics-decongestants that tighten the bladder neck (Afrin, Sudafed, the bladder neck (Afrin, Sudafed, Dexedrine, Phenylephrine)Dexedrine, Phenylephrine)

PessariesPessaries

• A A pessary is a rubber device that is inserted is a rubber device that is inserted into the vagina until it touches the cervix. into the vagina until it touches the cervix. The pessary presses through the vaginal wall The pessary presses through the vaginal wall and supports the urethra. It also pinches the and supports the urethra. It also pinches the urethra closed to help retain urine in the urethra closed to help retain urine in the bladder and decrease bladder and decrease stressstress incontinence. incontinence. Some women with stress incontinence use a Some women with stress incontinence use a pessary just during activities that are likely to pessary just during activities that are likely to cause urine leakage, such as jogging. cause urine leakage, such as jogging. However, many pessaries can be worn all the However, many pessaries can be worn all the time. If you use a pessary, you should watch time. If you use a pessary, you should watch for possible vaginal and urinary tract for possible vaginal and urinary tract infections and see your health professional infections and see your health professional regularly. regularly.

SurgerySurgery

• Typically utilized to correct urethral Typically utilized to correct urethral hypermobility hypermobility

• Sling proceduresSling procedures

• Collagen injectionsCollagen injections

• Bladder “tack’Bladder “tack’

Diagnostic EvaluationsDiagnostic Evaluations

• Urodynamics-to determine voiding Urodynamics-to determine voiding dysfunction etiology and bladder/urethra dysfunction etiology and bladder/urethra functionfunction

• Focused Physical examination and historyFocused Physical examination and history

• Dexterity testingDexterity testing

• Pelvic muscle strength testingPelvic muscle strength testing

• Prostate examProstate exam

• Cystoscopy to visualize bladder wall and Cystoscopy to visualize bladder wall and identify lesions.identify lesions.

Remember, Remember, incontinence is incontinence is

sometimessometimes curable, curable, oftenoften treatable, but treatable, but AlwaysAlways manageable. manageable.