Chapter 23

1. Chapter 23 Incontinence

2. Learning Objectives • Identify the types of urinary and fecal incontinence. • Explain the pathophysiology and treatment of specific types of incontinence. • Identify common therapeutic measures used for the patient with incontinence. • List nursing assessment data needed to assist in the evaluation and treatment of incontinence. • Assist in developing a nursing care plan for the patient with incontinence.

3. Incontinence Definition Involuntary passage of urine (urinary incontinence) or feces (fecal incontinence) Many conditions and situations can cause either temporary or permanent incontinence Person with incontinence: physical, psychosocial, financial burdens The management of incontinence in patient care settings requires many hours of nursing care Treatment goals: restore or improve treatable incontinence, manage irreversible incontinence, and prevent complications

4. Urinary Incontinence: Prevalence and Costs Surveys found that 5%-25% note leakage at least once a week and 5%-15% experience it daily or most of the time Among U.S. women who live in the community, 15%-50% have urinary incontinence; 7%-10% have severe leakage Although twice as common in women compared with men, 17% of men older than age 60 also have this condition Among men who have had a radical prostatectomy, as many as 30% have some degree of incontinence

5. Urinary Incontinence: Prevalence and Costs The cost of managing the incontinence in the United States is estimated to be more than $15 billion each year Health care providers need to recognize the economic and personal value of treating incontinence aggressively Nurses play an important role in educating people about the need for evaluation and treatment Urinary incontinence should not be considered a normal age-related change Often can be improved or cured

6. Physiology of Urination Urination or micturition The passage of urine Nurses and physicians commonly refer to the process of urinating as voiding Normal voiding requires healthy bladder muscles, a patent urethra, normal transmission of nerve impulses, and mental alertness Alterations in any of these factors may result in incontinence

7. Physiology of Urination Bladder receives urine continuously from the kidneys Bladder function: store urine until it can be eliminated Bladder walls are muscular and capable of stretching When 200-250 mL of urine collects in the bladder, stretch and tension receptors are stimulated The bladder contracts, and the internal sphincter relaxes Message sent to the brain, making person aware of the need to void Because voiding is normally voluntary, it can be delayed Then the external sphincter can be relaxed, permitting urine to flow out through the urethra

8. Figure 23-1

9. Diagnostic Tests and Procedures

10. Laboratory Tests Clean-catch urinalysis with culture and sensitivity testing usually ordered to assess for infection The specimen is studied for bacteria, red blood cells, white blood cells, and glucose; catheterization may be necessary A blood sample collected to measure blood urea nitrogen, creatinine, glucose, and calcium

11. Postvoid Residual Amount of urine remaining in the bladder after voiding One method: catheterize patient immediately after voiding; measure amount of urine obtained A second method is to use an ultrasound device to estimate the amount of urine remaining in the bladder after voiding Normally less than 50 mL of urine remains More than 199 mL reflects inadequateemptying

12. Diagnostic Tests and Procedures Imaging procedures Computed tomography Magnetic resonance imaging

13. Urodynamic Testing Assess the neuromuscular function of the lower urinary tract These tests indicated when cause of incontinence cannot be determined by simpler means

14. Uroflowmetry Measures voiding duration and the amount and rate of urine voided The patient voids into the funnel of the flowmeter Patient’s position for each voiding is recorded Fluid intake measured during testing period

15. Cystometry Evaluates neuromuscular function of the bladder The patient voids into a flowmeter, after which a catheter is inserted and the postvoid residual is measured Fluid, air, or both instilled into bladder; patient’s sensations and bladder response determined Bladder is filled until patient feels uncomfortable or it is apparent that the patient is unable to sense the pressure Bladder drained, or patient is permitted to void

16. Provocative Stress Testing Detects involuntary passage of urine when abdominal pressure increases Patient may be in a standing or lithotomy position The physician encourages the patient to relax and then to cough vigorously Examiner observes for urine loss during coughing

17. Cystoscopy A scope is inserted through urethra to visualize urethra and bladder Procedure may be done under local or general anesthesia Postprocedure care includes monitoring urine output and encouraging fluid ingestion

18. Common Therapeutic Measures

19. Bladder Training Patient education Information about normal urinary anatomy and physiology and the bladder retraining program Scheduled toileting The patient is encouraged to delay voiding and void only at scheduled times Positive reinforcement The patient’s efforts and improvement are positively reinforced throughout the treatment period, which usually lasts several months

20. Habit Training Similar to bladder training in that patient is encouraged to void at scheduled intervals The difference is that the patient is not advised to resist the urge and delay voiding The voiding schedule is based on the patient’s usual pattern

21. Prompted Voiding Often used with habit training for people who are dependent or cognitively impaired Caregiver checks the patient for wetness at regular intervals and asks the patient to state whether wet or dry Caregiver encourages the patient to try to use the toilet Caregiver praises patient for trying to use the toilet and for remaining dry

22. Pelvic Muscle Rehabilitation Aims to strengthen the pelvic floor Kegel exercises Actively exercise the pubococcygeus muscle Biofeedback Electronic or mechanical sensors are used to help the patient isolate the appropriate pelvic muscles to contract while keeping the abdominal muscles relaxed

23. Pelvic Muscle Rehabilitation Vaginal weights Ceramic devices of various weights are inserted into the vagina Begins with lightest cone, inserts it, and tries to retain it for up to 15 minutes twice daily When lightest cone successfully retained, heavier cones then used in succession

24. Urge Suppression If you have the urge to void, stop what you are doing; sit down or stand quietly Quickly squeeze the pelvic floor muscles several times without resting between squeezes Take a few deep breaths and try to relax except for the pelvic floor muscles Try to suppress the urge to void Wait until the urge passes While continuing to squeeze the pelvic floor muscles, walk to the bathroom at a normal pace

25. Reflex Training Uses the Valsalva maneuver with rectal stretching to force urine from the bladder Valsalva maneuver performed by taking a deep breath, holding it, and bearing down At the same time, the rectum is stretched by inserting a gloved finger into the rectum and pulling toward the back This creates pressure on the urinary sphincter and relaxes the pelvic floor, allowing urine to flow Patients who use this method should be checked for residual volume at times

26. Drug Therapy Anticholinergics Smooth muscle relaxants Calcium channel blockers Tricyclic antidepressant agents Nonsteroidal anti-inflammatory drugs Alpha-adrenergic agonists Estrogen

27. Drug Therapy Creams and sprays are available to coat and protect the skin of the perineum and buttocks of the incontinent patient A light dusting powder can be used to absorb moisture Cornstarch not recommended: promotes yeast infection development Do not use talc and lotion together on the same area because the combination creates an abrasive paste

28. Urine Collection Devices: External Useful for males Latex sheaths, sometimes called condom catheters or Texas catheters, drain urine into a bag that is usually secured to the leg Effective in maintaining dryness, but the adhesive may cause skin irritation on the penis Make sure the patient and all caregivers know not to encircle the penis with tape To do so can restrict circulation Use elastic tape; wrap in a spiral pattern

29. Urine Collection Devices Indwelling catheters To control urinary incontinence Usually done when all other measures have failed and skin integrity is endangered A catheter may also be needed temporarily if urine is coming in contact with a wound

30. Urine Collection Devices Intermittent self-catheterization Requires dexterity, adequate vision, and ability and motivation to learn Clean technique rather than sterile is usually taught for use in the home setting Initially the bladder is drained every 4 hours; adjusted according to amount of residual

31. Urine Collection Devices Garments and pads for incontinence Help maintain dryness Disposable briefs and pads “Geri pads” Washable waterproof briefs; absorbent cotton liners Another style: stretchy brief with a perineal pouch through which absorbent pads can be changed The best product is one that draws urine away from the skin through a liner that remains dry

32. Garments and Pads for Incontinence Penile clamp A device applied to the penis It compresses the urethra, preventing the passage of urine To prevent circulatory impairment and pressure sores, the clamp must be removed and repositioned frequently

33. Figure 23-2

34. Pelvic Organ Support Devices Pessary Device inserted into the vagina to hold the pelvic organs in place Sometimes used to treat incontinence in women with relaxation of pelvic structures A doughnut-shaped pessary exerts pressure on the vaginal wall, lifting the uterus and holding it in the pelvis Must be removed periodically for cleansing and replacement as needed

35. Pelvic Organ Support Devices Bladder neck support prosthesis For women with stress incontinence The Silastic device is fitted into the vagina It supports the area where the urethra connects to the bladder, thereby reducing the incidence of involuntary urine loss

36. Surgical Treatment Surgical procedures Remove obstructions Treat severe detrusor overactivity Implant an artificial sphincter Reposition the sphincter unit Improve perineal support Inject substances that increase urethral compression

37. Surgical Treatment Implantation of electrodes Electrostimulation: electrodes that stimulate the pelvic floor muscles Retropubic urethropexies and pubovaginal slings Surgical procedures most often used for stress urinary incontinence in women

38. Surgical Treatment Artificial sphincter Inflatable cuff, a reservoir of fluid that fills the cuff, and a pump Cuff is positioned around the urethra or bladder neck Reservoir is placed in the abdomen and the pump in the scrotum or labia Fluid fills the cuff, applying pressure to the urethra to prevent urine passage To void, patient compresses the pump, which deflates the cuff by transferring fluid from cuff to the reservoir and allowing urine to pass through the urethra

39. Figure 23-3

40. Types of Urinary Incontinence

41. Urge Incontinence The involuntary loss of urine shortly after a strong, abrupt urge to urinate Idiopathic urge incontinence A specific cause cannot be identified Neurogenic detrusor overactivity Associated with neurologic disorders, such as stroke, multiple sclerosis, and spinal cord lesions

42. Urge Incontinence Management Aimed at correcting the cause, if possible Behavioral techniques Drug therapy Surgical intervention

43. Overflow Incontinence Involuntary urine loss from overdistended bladder Small amounts of urine are lost continuously or at frequent intervals Contributing factors Obstruction to urine flow, an underactive detrusor muscle, or impaired transmission of nerve impulses Patients not aware of bladder fullness, and the bladder may become overdistended Neurogenic bladder: retention with overflow caused by neurologic dysfunction associated with spinal cord injury, radical pelvic surgery, or radiation cystitis

44. Overflow Incontinence Management Depends on the cause The physician may prescribe drugs to stimulate the bladder and relax the internal sphincter Surgical removal of all or part of the prostate Sphincterotomy Intermittent or indwelling catheterization Credé’s method Valsalva maneuver Anal stretch maneuver

45. Stress Incontinence The involuntary loss of small amounts of urine during physical activity that increases abdominal pressure Coughing, laughing, sneezing, and lifting In women, caused by relaxation of the pelvic floor muscles and the urethrovesical juncture as a result of pregnancy, childbirth, obesity, and aging Urethral trauma, sphincter injury, congenital sphincter weakness, urinary infection, stress, and neurologic disorders cause stress incontinence in men and women It may occur after prostatectomy or radiation therapy

46. Stress Incontinence Management Behavioral methods Maintain a fluid intake of at least 2000 mL/day Avoid fluids with diuretic effect (tea, coffee, cola) Alpha-adrenergic drugs: pseudoephedrine HCl (Sudafed) Oral or topical estrogen Retropubic urethropexies, pubovaginal slings, and collagen injections

47. Functional Incontinence Description Voiding inappropriately because unable to get to the toilet or to manage the mechanics of toileting Related to confusion, immobility, or barriers in the environment

48. Functional Incontinence Management Depends on the cause Environment should be arranged to permit independent toileting Assistive devices enable immobile patient to void appropriately The confused patient may respond well to scheduled or timed voiding and efforts to improve orientation to toilet facilities

49. Nursing Care of the Patient with Urinary Incontinence

50. Health History Chief complaint Thorough description of chief complaint is essential Ask whether the patient is aware of the need to void and able to hold the urine once the need is felt Determine the pattern of incontinent voiding, urine volume, and related symptoms