Transcript Managing Urinary Incontinence

Managing
Urinary
Incontinence
Catherine Van Son, Ph.D., R.N.
“ 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.
Urinary Incontinence
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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)
UI is not reported
because of...
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embarrassment
lack of information
a belief it is part of aging
health care providers don’t ask
a belief there is no effective treatment
fear of the therapies used to manage the
problem
Psycho-social Impact
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loss of self esteem
embarrassment
decrease in ability to maintain
independence
social isolation
depression
anxiety
poor quality of life
risk of institutionalization
Self-care behaviors used:
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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
What is normal?
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daytime:
• frequency of no more than once every 2 hours
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nighttime:
• 1-2 voidings are considered normal
Age 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)
Forces that Affect the Pelvic Floor
Neurological
Anatomical
Why would the female
anatomy increase incidence
of urinary incontinence?
In which ways do the
nerves affect the pelvic
floor?
Pelvic Floor
Mechanical
What is the impact of
pregnancy, constipation,
and/ or prostate enlargement ?
Hormonal
How does estrogen
affect the pelvic floor?
Psychological
How would one’s psychological
status impact incontinence?
Risk factors for UI
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immobility/chronic degenerative disease
impaired cognition
medications
obesity
diuretics
fecal impaction, constipation
low fluid intake
environmental barriers
diabetes
stroke
Each of these factors can increase one’s
estrogen depletion
risk for experiencing urinary incontinence.
smoking
Often older adults experience more than one risk
factor at any given time.
Medications can cause...
frequency
 urgency
 retention
 fecal impaction
 polyuria
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nocturia
 immobility
 sedation
 delirium
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Incontinence History
Medical History?
 Frequency?
 Sensations?
 Medications?
 Amount?
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Incontinence Screening
“DRIP”
D
R
- delirium, depression
- retention, restricted mobility
and/or environment
I
- infection, inflammation,
impaction
P
- pharmaceuticals, polyuria, pain
NOTE: Any one
of these
conditions can
cause acute
onset urinary
incontinence
and must be
evaluated
promptly !
Kinds of Urinary
Incontinence
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Stress
Functional
Environmental
Urge
Overflow
Iatrogenic (caused by
hospitalization, medications,
etc.)
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Mixed
Stress Incontinence
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loss of urine that occurs during activities that increase
intra-abdominal pressure:
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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)
Pelvic Floor Muscle
Exercises
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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?)
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Like all exercises; success depends on
doing them regularly.
Functional 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?
Functional 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.)
Environmental
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), I’ll clean you up later.”
“S/he does that on purpose.” (Episodes of incontinence)
delay in removing wet clothing
Environmental Assessment
location/ accessibility of toilets
signs for bathroom
call lights/ bells
adaptive equipment
cleanliness, safety
A 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.
Bathroom 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?
Solution
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
Urge Incontinence is…
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a loss of urine with an abrupt and strong desire to void.
• “I’m 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, Parkinson’s disease, or
multiple sclerosis
Urge Incontinence:
Treatment
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Behavioral therapy
• bladder training
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Electrical Stimulation
• biofeedback
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Medications
Bladder Retraining
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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.)
Overflow 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
When to Refer?
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marked pelvic prolapse
marked prostate enlargement
difficulty passing a 14 Fr. catheter
most cases of overflow
hematuria
treatment failures
Treatment 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)
Management of UI
is a team effort
Must involve:
 the client
 family
 caregiver(s)
 nursing
 primary care provider
 dietician
 PT/OT/RT/SLP
 management
Behavioral
Interventions
are non-invasive
 involve caregiver and individual
 measure outcomes
 are inexpensive
 are effective
 are low risk
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Unlocking UI:
Behavioral Methods
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assessments
food and fluid changes
pelvic floor muscle exercises
bladder retraining
education
Bladder (Voiding) Record
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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
Example of Voiding Record
Time
Interval
6-8am
8-10 am
ETC.
Urinated Sm. UI
in toilet episode
Lg. UI
episode
Reason
For UI
Type/amt
Of fluid
intake
Physical Exam
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Abdominal/Pelvic/Genitalia/Rectal exam
Neurological Status
Dexterity
Mental Status
Mobility
Maintain/Promote Mobility
assessments by OT / PT / SLP
 use of assistive devices
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walkers, canes
exercise programs
 proper shoes
 foot care
 uncluttered walkways
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Absorbent Products
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trial and error
evaluate products for...
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skin irritation
noise
comfort
odor control
ease of use/ability to change
absorption
confidence
Factors to consider with
absorbent products
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skin integrity
comorbidity
optimal product for
client
incidence of
vaginitis/
bacteriuria
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functional disability of
client
type and severity of UI
gender
availability of
caregivers
previous treatment
programs
client preference
Mild to Moderate UI
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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)
Chronic
Incontinence
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scheduled toileting
improved access to toilets
fluid and diet management
absorbent garments/ devices
change clothes when wet
Food & Fluids
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aim for 1500-2000 ml/day
• include jello, soups, popsicles, water-packed
fruits etc. (caution with diabetics)
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avoid bladder irritants
• such as caffeine and chocolate
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avoid evening fluids
treat dependent edema
• elevation during the day
• compression stockings
• decrease sodium intake
Frequent UTI’s
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Cranberry juice, 10 oz daily
• must have at least 25% cranberry
juice
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Check fluid intake
Check post-void residual
Change catheter or remove
Dementia
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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.)
UI and Dementia:
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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
Habit Training
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voiding at predetermined times
goal: to decrease/eliminate number of
incontinent episodes (keep dry)
fixed time intervals
allows for schedule adjustments
requires commitment
Caregiver assessment
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Availability of caregivers?
Caregivers have the knowledge
they need to manage urinary
incontinence? (Schedules, safe transfers,
signs/symptoms of UTI)
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Are caregivers willing to help with
continence?
Do caregivers have the equipment
they need? (such as a gait belt for safe
transfers)
Caregiver frustration
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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
To ponder...
The bladder is the
mirror of the soul.
Chinese proverb
When you gotta go
nothing else
really matters!
Urinary Incontinence was prepared by Catherine Van Son, Ph.D,
R.N. for the Older Adult Focus Project, OHSU School of Nursing.