Transcript Continence Management in the Stroke Population

Managing Urinary
Incontinence Post Stroke
Telehealth Presentation for Alberta Provincial Stroke Strategy
April 23, 2009
Laura Robbs, RN, BScN, MN, ET, NCA
Clinical Nurse Specialist-Continence,
Trillium Health Centre
Mississauga, Ontario
Learning Objectives:
Review normal bladder function
 review common types of urinary
incontinence
 Discuss the impact of stroke on
urinary continence
 discuss strategies for promoting
urinary continence post stroke

What is urinary incontinence
(UI)?
It has been defined by the International
Continence Society as:
“a condition where involuntary loss of
urine is a social or hygienic problem”
(ICS, 1988)
Responses to UI:
Fear
 embarrassment
 shame
 anxiety
 frustration
 guilt
 anger

Relationship between UI &
Quality of Life:
Greatest negative impact on
emotional and social well being
 UI is embarrassing, socially disruptive
with multiple effects on daily activities
and interpersonal relationships
 does not appear to have devastating
psychological consequences

Who is affected by UI?

General population:



1 in 4 women
1 in 10 men
post stroke:


32-79% people on admission
25-28% on discharge
 ↑ risk of falls, fractures & hospitalization

triples the risk of long term care placement
Bladder function:
Voluntary & reflexive control
 Bladder - muscular balloon constantly
filling under low pressure
 Bladder stretch receptors send
impulse through SC to the brain
 stimulates a response causing
bladder to contract & allows external
sphincter to relax

Bladder function (continued):

Therefore urine is expelled as the
bladder contracts, internal sphincter
opens & external sphincter relaxes

Key: brain able to reduce urge and
delay urination
Bladder pressure
Normal
Micturition
Cycle
Bladder filling
Detrusor muscle
relaxes
+
Urethral
Sphincter
tone
+
Pelvic floor
tone
Storage phase
First sensation
to void
Detrusor muscle
relaxed
+
Urethral
Sphincter
contracts
+
Pelvic floor
contracts
Emptying phase
Normal desire
to void
Bladder filling
Detrusor muscle
contracts
+
Urethral
Sphincter
Relaxes
(Voluntary control)
+
Pelvic floor
Relaxes
MICTURITION
Detrusor muscle
relaxes
+
Urethral
Sphincter
tone
+
Pelvic floor
tone
Bladder function: storage &
voiding

400-600 ml maximum bladder
capacity (less with aging)

first desire to void at 300 ml

“normal” voiding frequency 4-8 times
per day and once at night
CNS control of bladder:
CNS control of bladder
functioning:

Cortical Centre

frontal lobes are key to controlling the
bladder by inhibiting detrusor (bladder
muscle) contractions and their
connection to the sacral roots via the
SC is critical
CNS control of bladder
functioning:

Pontine centre
receives input from the cerebral cortex
 coordinates detrusor contraction and
urethral relaxation
 inhibitory impulses from the pontine
centre allows bladder to store urine

CNS control of bladder
functioning:

Sacral Centre

mechanism that mediates voiding in
infants and in adults following SCI
above the lumbosacral spinal
segments
Types of incontinence
anyone can experience:
 Stress
 urge
 overflow
 functional
Stress incontinence:
Not related to CVA - most common UI
in women
 sudden increase in intra-abdominal
pressure (laugh, cough, exercise)
 related to weak pelvic floor muscles,
loss of estrogen, positioning of
bladder or urethra
 Can occur in men post radical
prostatectomy

Urge incontinence:
Loss of urine with a strong
unstoppable urge to urinate
 S&S: frequency day & night, UI on
way to bathroom, small voided
volumes, common in men & women
 Common in neurological
injury/condition e.g. CVA
 Also known as “overactive bladder”

Overflow Incontinence:
Bladder full at all times & leaks any
time
 related to partial obstruction of
bladder neck (e.g. enlarged prostate,
pelvic prolapse in women), secondary
to medication, fecal impaction,
diabetes or lower SCI
 S&S: dribbling, urgency, frequency,
hesitancy

Functional Incontinence:
UI that results from barriers that
prevent the person from getting to the
BR in time
 e.g. impaired cognitive functioning
(Alzheimer’s), or impaired physical
functioning (arthritis)

Stroke & UI: depends on
part of brain affected
How strokes affect UI:
FRONTAL STROKE
voluntary control of the external
sphincter but uninhibited bladder
contraction
 strong urge to void with short/no
warning
 persistent frequency, nocturia, urge
incontinence

Parietal & Basal Ganglion
Stroke:
Uninhibited bladder contraction
 voiding is obstructed as the bladder
and urethral sphincter contract at the
same time
 may lead to ureter reflux and renal
damage
 overflow incontinence

Hemispheric Stroke:

Secondary to immobility and
dependency on others rather than
direct effects from the stroke
Additional risk factors for UI:





Urinary tract infections
caffeine intake
low fluid intake
constipation
weak pelvic floor
muscles




mobility impairment
cognitive impairment
environmental barriers
medications e.g.
diuretics, sedatives
Assessment of Urinary
Incontinence
Incontinence history
 Fluid intake
 Bowels
 Medical history
 Medications
 Functional ability
 Voiding record

Incontinence History
Onset
 Duration
 Daytime/nighttime
 Accidents
 Stress loss
 Urge loss
 Aware of loss?

Fluid intake
How much
 Restrictions
 Caffeine
 alcohol

bowels
Pattern
 Constipation
 Diet
 Laxatives

Medical history:
Stroke
 Parkinson’s
 Multiple Sclerosis
 Diabetes
 Repeated urinary tract infections
 Acquired brain injury
 Dementia

medications
Diuretics
 Anticholinergics
 Estrogen
 Sedatives/hypnotics
 Antidepressants

Functional ability
Access to bathroom
 Ambulation



Needs assistance
wheelchair
Impact of cognitive impairment
on ability to be continent:
Ability to follow & understand prompts
or cues
 Ability to interact with others
 Ability to complete self care tasks
 Social awareness

Physical assessment:
Post residual volume
 urine culture
 vaginal examination
 rectal examination


Voiding record:

time and amount of fluid intake, urine
voided, incontinence x 3-4 days
Conservative treatment all
team members can do:

Client/family focused
using education
 behaviour modification
 problem solving strategies

Fluid intake changes





Reduce/eliminate caffeine intake
reduce/eliminate alcohol intake
ensure adequate fluid intake
(1500-2000 ml)
Temporarily reduce intake when going out
(urgency)
Nothing to drink two hours prior to going to
bed for the night
Pelvic muscle exercises
(Kegel’s)
Strengthen pelvic floor muscles
 helps with stress or urge UI
 need more than verbal instruction
 Tighten anal sphincter as if you do not
want to pass rectal gas
 hold contraction for count of 3 then
relax for 3

Urge suppression strategies
pelvic floor exercises
 urge suppression using distraction
techniques
 aim: gradually  voiding intervals &
voiding volumes (300-400 ml)
 voiding/prompted voiding q 3 hours

Treatment Medications:
Anticholinergics:
Reduce irritability of the bladder
 larger bladder volumes
 reduces frequency
 Available in long acting dose


e.g. Oxybutinin(Ditropan), Tolterodine
(Detrol),
Anticholinergics

potential side effects:
dry mouth
 drowsiness, fatigue
 altered mentation with diminished
ability for complex problem solving
 hypertension, tachycardia
 insomnia

Treatment Medications:
Estrogen
Local estrogen cream, suppositories
or estring helpful with atrophic vaginal
changes
 help with symptomatic complaints of
dryness, UI, UTI

Toileting strategies:
less severely
cognitively impaired & more mobile benefit more

Timed voiding
Person is toileted on a schedule &
voiding recorded on chart
 Their schedule can be gradually adapted
to match their individualized voiding
schedule
Prompted voiding
 person again toileted on regular schedule
but is asked if they need assistance


Prompted voiding:
↓ number of incontinent episodes/day
& ↑ number of continent voids
 Can be used with people with physical
or mental impairments
 Identification of individual voiding
patterns rather than routine toileting
e.g. q2h can be more successful
 Determine individual voiding pattern
by voiding record

Vaginal pessaries

Worn intra-vaginally to support
cystocele or uterine prolapse
Products

Use pads made for urine loss

not menstrual pads, facecloths or
tissue
pads for men
 Night time briefs helpful during
heavier wetting times
 use unscented, mild soap sparingly

Referral to medical specialist
(urologist, urogynecologist, gynecologist):
Significant post void residual
 abnormal urine dipstick test
 pelvic organ prolapse
 constant dribbling
 frequent UTI’s
 No response to conservative
treatment

Questions/Comments?
Laura Robbs, Clinical Nurse SpecialistContinence
Trillium Health Centre
905-848-7580 ext. 3267
[email protected]
References:



Coleman Gross, J. (2003). Urinary incontinence after stroke: Evaluation
behavioral treatment. Topics In Geriatric Rehabilitation. 19(1):
60-84.
Harari, D., Norton, C., Lockwood, L., & Swift, C. (2004). Treatment of
constipation and fecal incontinence in stoke patients: Randomized
control trial. Stroke. 35(11): 2529-2555.
Smith, T.L. (2008). Medical complications of stroke. Up To Date.
www.uptodate.com
and