Managing Urinary Incontinence

1. Managing 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.

3. Urinary 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 (althoughphysiological 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 don’t ask • a belief there is no effective treatment • fear of the therapies used to manage the problem

5. Psycho-social Impact • loss of self esteem • embarrassment • decrease in ability to maintain independence • social isolation • depression • anxiety • poor quality of life • risk of institutionalization

6. Self-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

7. What is normal? • daytime: • frequency of no more than once every 2 hours • nighttime: • 1-2 voidings are considered normal

8. 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)

9. Forces 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 one’s psychological status impact incontinence?

10. Risk 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 one’s risk for experiencing urinary incontinence. Often older adults experience more than one risk factor at any given time.

11. frequency urgency retention fecal impaction polyuria nocturia immobility sedation delirium Medications can cause...

12. Incontinence History • Medical History? • Frequency? • Sensations? • Medications? • Amount?

13. Incontinence Screening“DRIP” 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

14. Kinds of Urinary Incontinence • Stress • Functional • Environmental • Urge • Overflow • Iatrogenic (caused by hospitalization, medications, etc.) • Mixed

15. Stress 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)

16. Pelvic 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.

17. 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?

18. 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.)

19. 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

20. Environmental Assessment • location/ accessibility of toilets • signs for bathroom • call lights/ bells • adaptive equipment • cleanliness, safety

21. 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.

22. 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?

23. 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

24. Urge Incontinence is… • 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

25. Urge Incontinence: Treatment • Behavioral therapy • bladder training • Electrical Stimulation • biofeedback • Medications

26. Bladder 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.)

27. 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

28. When to Refer? • marked pelvic prolapse • marked prostate enlargement • difficulty passing a 14 Fr. catheter • most cases of overflow • hematuria • treatment failures

29. 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)

30. Management of UI is a team effort Must involve: • the client • family • caregiver(s) • nursing • primary care provider • dietician • PT/OT/RT/SLP • management

31. Behavioral Interventions • are non-invasive • involve caregiver and individual • measure outcomes • are inexpensive • are effective • are low risk

32. Unlocking UI: Behavioral Methods • assessments • food and fluid changes • pelvic floor muscle exercises • bladder retraining • education

33. Bladder (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

34. Example of Voiding Record

35. Physical Exam • Abdominal/Pelvic/Genitalia/Rectal exam • Neurological Status • Dexterity • Mental Status • Mobility

36. Maintain/Promote Mobility • assessments by OT / PT / SLP • use of assistive devices • walkers, canes • exercise programs • proper shoes • foot care • uncluttered walkways

37. Absorbent Products • trial and error • evaluate products for... • skin irritation • noise • comfort • odor control • ease of use/ability to change • absorption • confidence

38. 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 Factors to consider withabsorbent products

39. Mild 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

41. Food & 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

42. Frequent UTI’s • Cranberry juice, 10 oz daily • must have at least 25% cranberry juice • Check fluid intake • Check post-void residual • Change catheter or remove

43. Dementia • 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.)

44. UI 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

45. Habit Training • voiding at predetermined times • goal: to decrease/eliminate number of incontinent episodes (keep dry) • fixed time intervals • allows for schedule adjustments • requires commitment

46. Caregiver 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)

47. Caregiver 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

48. To ponder... The bladder is the mirror of the soul. Chinese proverb When you gotta go nothing else really matters!

49. Urinary Incontinence was prepared by Catherine Van Son, Ph.D, R.N. for the Older Adult Focus Project, OHSU School of Nursing.