Urinary Incontinence

1. Urinary Incontinence Barbara Dale RN CWON CHHN Quality Home Health September 25, 2006

2. Urinary Incontinence • Urinary incontinence is defined as the involuntary leakage of urine from the bladder • Urinary Incontinence affects 17 million people in the United States every year with 85% of them women • One in three persons over age 60 are affected by urinary incontinence • 38% of women over 60 are affected • 87% of all forms of incontinence can be effectively managed http://kidney.niddk.nih.gov/kudiseases/pubs/kustats/index.htm

3. Causes • Hormonal changes • Weakened pelvic muscles r/t childbirth • Prostate disorders/surgery • Pelvic trauma • Spinal cord damage • Caffeine • Medications • Neurological/Cognitive disorders such as MS & Alzeimer’s

4. Urinary incontinence is not a natural part of aging. It can happen at any age, and can be caused by many physical conditions. Many causes of incontinence are temporary and can be managed with simple treatment. Some causes of temporary incontinence are: • Urinary tract infection • Vaginal infection or irritation • Constipation • Effects of medicine

5. Voiding Physiology • Normal voiding requires coordination between multiple structures and nerve pathways. • Key structures include the brain, brainstem, spinal cord, bladder, and urethral sphincter mechanism.

6. The Brain and Social Continence • The brain(cerebral cortex) provides overall control and direction of bladder function. • The Detrusor area in the cerebral cortex controls bladder function by directing the micturition centers to initiate or delay voiding depending on the social situation. This is called social continence • Any disruption in the cerebrocortical function can cause or contribute to incontinence. • CVA is a common cause of incontinence because the two most common arteries involved in CVA are the same two that supply the detrusor area of the brain.

7. Brainstem • The pontine micturition center in the brainstem provides for automatic coordinated voiding. Meaning the urethra opens before the bladder contracts. • The pons also holds the micturition ‘reflex’ center which allows the bladder to empty when reaching a certain fullness irregardless of social situation. Especially important for spinal cord patients.

8. Spinal Cord Pathways • Parasympathetic-comes off at S2-S4 and cause the bladder to contract and the urethra to relax. Parasympathetic stimulation initiates voiding. • Sympathetic pathways come off at T-10 L2 that cause bladder neck to tighten and also contribute to bladder relaxation. Sympathetic stimulation contributes to urine storage and promotes continence.

10. Bladder, Urethra, and Sphincters

11. Types of Incontinence • Stress • Urge • Mixed stress/urge • Overflow (retention)

12. People with urge incontinence lose urine as soon as they feel a strong need to go to the bathroom.(AKA Overactive bladder)If you have urge incontinence you may leak urine: • When you can't get to the bathroom quickly enough • When you drink even a small amount of liquid, or when you hear or touch running water • You may go to the bathroom very often; for example, every two hours during the day and night • You may even wet the bed

13. Urge Incontinence Causes/Risk Factors • Aging is a risk factor simply due to reduced bladder capacity, delayed recognition of bladder filling resulting in reduced “response” time. • Bladder irritants, neurological lesions, stones, cancer, obstructed flow. • Idiopathic

14. People with stress incontinence lose urine when they exercise or move in a certain way. If you have stress incontinence, you may leak urine: • When you sneeze, cough, or laugh • When you get up from a chair or out of bed • When you walk or do other exercise • You may also go to the bathroom often during the day to avoid accidents.

15. People with overflow incontinence may feel that they never completely empty their bladder. If you have overflow incontinence, you may: • Often lose small amounts of urine during the day and night • Get up often during the night to go to the bathroom • Often feel as if you have to empty your bladder but can't • Pass only a small amount of urine but feel as if your bladder is still partly full • Spend a long time at the toilet, but produce only a weak, dribbling stream of urine

16. Overflow Incontinence Causes • People with overflow incontinence do not feel the urge to urinate. The bladder never empties normally and remains at least partially full; small amounts of urine are leaked on a nearly continuous basis. Weak bladder muscles -- caused by nerve damage from diabetes or other diseases -- or a blocked urethra can be responsible for overflow incontinence. • Overflow incontinence most frequently appears in older men in whom an enlarged prostate hinders the flow of urine; urinary stones or tumors also may block the urethra. Overflow incontinence is rare in women, although sometimes it is caused by fibroid or ovarian tumors. Spinal cord injuries or nervous system disorders are additional causes of overflow incontinence.Some of the symptoms of overflow incontinence are:Feeling as though the bladder is never completely empty.Feeling the urge to urinate, but not being able to.Passing a dribbling stream of urine, even after spending a long time at the toilet.Frequently getting up at night to urinate.Although some people with overflow incontinence never have the feeling of a full bladder, they may leak urine day and night.

17. Functional Incontinence • Diagnosis: Usually one of elimination. Patient voids large amounts at regular intervals. • Incontinence in patient with normal voiding patterns and normal bladder function, usually related to cognitive status, motivation, and/or mobility issues. • Cortex doesn’t process the signals from the bladder. An automatic voiding when bladder is full. No social continence. • Tx: prompted or timed voiding. Containment products and skin care.

18. Treatments • Pelvic Muscle Rehabilitation • Behavioral therapy • Pharmacological Therapies • Pessary • Surgical Therapies

19. Assessment and Evaluation • MD/UNP/WOCN • DIAPPERS • Bladder Diary

20. DIAPPERS D-Delirium I- Infection A-Atrophic urethritis/vaginitis P-Pharmaceuticals P-Psychological Status E-Endocrine changes R-Restricted mobility S-Stool Impaction

21. Pelvic Muscle Rehabilitation • Kegels • Vaginal weights • Biofeedback

22. Kegel Exercises • The first step is to find the right muscles. Imagine that you are sitting on a marble and want to pick up the marble with your vagina. Imagine “pulling" the marble up into your vagina. • Try not to squeeze other muscles at the same time. Be careful not to tighten your stomach, legs, or buttocks. Squeezing the wrong muscles can put more pressure on your bladder control muscles. Just squeeze the pelvic muscles. Don't hold your breath. Do not practice while urinating.

23. Repeat, but don't overdo it. At first, find a quiet spot to practice—your bathroom or bedroom—so you can concentrate. Pull in the pelvic muscles and hold for a count of 3. Then relax for a count of 3. Work up to 3 sets of 10 repeats. Start doing your pelvic muscle exercises lying down. This is the easiest position to do them because the muscles do not need to work against gravity. When your muscles get stronger, do your exercises sitting or standing. Working against gravity is like adding more weight. • Be patient. Don't give up. It takes just 2-5 minutes a day. You may not feel your bladder control improve for 3 to 6 weeks. Still, most people do notice an improvement after a few weeks.

24. Behavioral Therapies • Scheduled toileting • Prompted voiding • Improved access to toilets • Managing fluids and diet • Disposable absorbent undergarments

25. Bladder Training • Bladder training has many variations but generally consists of three primary components: • Education • Scheduled voiding • Positive reinforcement

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

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

29. Timed Voiding Management • Goal: To keep patient dry(at least during waking hours) by toileting him/her often enough to prevent incontinence. • Guidelines: Determine patients usual voiding frequency by having caregiver complete bladder chart/diary. Instruct caregiver to take patient to bathroom according to schedule and “cue” to void. Alternative in LTC environment that may be more effective is ADL based schedule: upon arising, after lunch, before supper, and at bedtime.

30. Trouble shooting Timed voiding • Pt who is voiding small amounts needs to be evaluated for additional factors contributing to bladder dysfunction and incontinence such as infection, impaction, retention, bladder irritants. If reversible factors and retention have been ruled out, consult MD for possible trial of anticholinergics.

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

32. Pharmacological Work on parasympathetic nervous system • Cholinergics • Urecholine promotes bladder contractility/reduce retention • Anticholinergics • Ditropan reduces sensory urgency and bladder contractility

33. Medications that affect Continence • Sedatives (hypnotics, alcohol) • Diuretics • Anticholinergic drugs (antipsychotics, antidepressants, antihistamines, anti-Parkinson’s, antiarrhythmics, antispasmodics, antidiarrheals) • Antihypertensive drugs that relax smooth muscle including the bladder neck (catapres, aldomet, minipress) • Adrenergics-decongestants that tighten the bladder neck (Afrin, Sudafed, Dexedrine, Phenylephrine)

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

35. Surgery • Typically utilized to correct urethral hypermobility • Sling procedures • Collagen injections • Bladder “tack’

36. Diagnostic Evaluations • Urodynamics-to determine voiding dysfunction etiology and bladder/urethra function • Focused Physical examination and history • Dexterity testing • Pelvic muscle strength testing • Prostate exam • Cystoscopy to visualize bladder wall and identify lesions.

37. Remember, incontinence is sometimes curable, often treatable, but Always manageable.