Notes
Definition
Urinary incontinence (UI) is any involuntary leakage of urine. It can be a common and distressing problem, which may have a profound impact on quality of life. Urinary incontinence almost always results from an underlying treatable medical condition but is under-reported to medical practitioners. There is also a related condition for defecation known as fecal incontinence.
Causes
- Polyuria (excessive urine production) of which, in turn, the most frequent causes are: uncontrolled diabetes mellitus, primary polydipsia (excessive fluid drinking), central diabetes insipidus and nephrogenic diabetes insipidus.Polyuria generally causes urinary urgency and frequency, but doesn’t necessarily lead to incontinence.
- Caffeine or cola beverages also stimulate the bladder.
- Enlarged prostate is the most common cause of incontinence in men after the age of 40; sometimes prostate cancer may also be associated with urinary incontinence. Moreover drugs or radiation used to treat prostate cancer can also cause incontinence.
- Disorders like multiple sclerosis, spina bifida, Parkinson’s disease, strokes and spinal cord injury can all interfere with nerve function of the bladder.
Pathophysiology
Continence and micturition involve a balance between urethral closure and detrusor muscle activity. Urethral pressure normally exceeds bladder pressure, resulting in urine remaining in the bladder. The proximal urethra and bladder are both within the pelvis. Intraabdominal pressure increases (from coughing and sneezing) are transmitted to both urethra and bladder equally, leaving the pressure differential unchanged, resulting in continence. Normal voiding is the result of changes in both of these pressure factors: urethral pressure falls and bladder pressure rises.
Diagnosis
Patients with incontinence should be referred to a medical practitioner specializing in this field. Urologists specialize in the urinary tract, and some urologists further specialize in the female urinary tract. A urogynecologist is a gynecologist who has special training in urological problems in women. Family physicians and internists see patients for all kinds of complaints, and are well trained to diagnose and treat this common problem. These primary care specialists can refer patients to urology specialists if needed.
A careful history taking is essential especially in the pattern of voiding and urine leakage as it suggests the type of incontinence faced. Other important points include straining and discomfort, use of drugs, recent surgery, and illness.
The physical examination will focus on looking for signs of medical conditions causing incontinence, such as tumors that block the urinary tract, stool impaction, and poor reflexes or sensations, which may be evidence of a nerve-related cause.
A test often performed is the measurement of bladder capacity and residual urine for evidence of poorly functioning bladder muscles.
Other tests include:
- Stress test – the patient relaxes, then coughs vigorously as the doctor watches for loss of urine.
- Urinalysis – urine is tested for evidence of infection, urinary stones, or other contributing causes.
- Blood tests – blood is taken, sent to a laboratory, and examined for substances related to causes of incontinence.
- Ultrasound – sound waves are used to visualize the kidneys, ureters, bladder, and urethra.
- Cystoscopy – a thin tube with a tiny camera is inserted in the urethra and used to see the inside of the urethra and bladder.
- Urodynamics – various techniques measure pressure in the bladder and the flow of urine.
Patients are often asked to keep a diary for a day or more, up to a week, to record the pattern of voiding, noting times and the amounts of urine produced.
Types
- Stress incontinence, also known as effort incontinence, is due essentially to insufficient strength of the pelvic floor muscles.
- Urge incontinence is involuntary loss of urine occurring for no apparent reason while suddenly feeling the need or urge to urinate.
- Overflow incontinence: Sometimes people find that they cannot stop their bladders from constantly dribbling or continuing to dribble for some time after they have passed urine. It is as if their bladders were constantly overflowing, hence the general name overflow incontinence.
- Mixed incontinence is not uncommon in the elderly female population and can sometimes be complicated by urinary retention, which makes it a treatment challenge requiring staged multimodal treatment.
- Structural incontinence: Rarely, structural problems can cause incontinence, usually diagnosed in childhood (for example, an ectopic ureter). Fistulas caused by obstetric and gynecologic trauma or injury can lead to incontinence. These types of vaginal fistulas include, most commonly, vesicovaginal fistula and, more rarely, ureterovaginal fistula. These may be difficult to diagnose. The use of standard techniques along with a vaginogram or radiologically viewing the vaginal vault with instillation of contrast media.
- Functional incontinence occurs when a person recognizes the need to urinate but cannot make it to the bathroom. The urine loss may be large. Causes of functional incontinence include confusion, dementia, poor eyesight, poor mobility, poor dexterity, unwillingness to toilet because of depression, anxiety or anger, drunkenness, or being in a situation in which it is impossible to reach a toilet.People with functional incontinence may have problems thinking, moving, or communicating that prevent them from reaching a toilet. A person with Alzheimer’s Disease, for example, may not think well enough to plan a timely trip to a restroom. A person in a wheelchair may be blocked from getting to a toilet in time. Conditions such as these are often associated with age and account for some of the incontinence of elderly women and men in nursing homes.Disease or biology is not necessarily the cause of functional incontinence. For example, someone on a road trip may be between rest stops and on the highway; also, there may be problems with the restrooms in the vicinity.
- Bedwetting is episodic UI while asleep. It is normal in young children.
- Transient incontinence is a temporary version of incontinence. It can be triggered by medications, adrenal insufficiency, mental impairment, restricted mobility, and stool impaction (severe constipation), which can push against the urinary tract and obstruct outflow.
- Giggle incontinence is an involuntary response to laughter. It usually affects children.
In women
Bladder symptoms affect women of all ages. However, bladder problems are most prevalent among older women.Up to 35% of the total population over the age of 60 years is estimated to be incontinent, with women twice as likely as men to experience incontinence. One in three women over the age of 60 years are estimated to have bladder control problems.
Bladder control problems have been found to be associated with higher incidence of many other health problems such as obesity and diabetes. Difficulty with bladder control results in higher rates of depression and limited activity levels.
Incontinence is expensive both to individuals in the form of bladder control products and to the health care system and nursing home industry. Injury related to incontinence is a leading cause of admission to assisted living and nursing care facilities. More than 50% of nursing facility admissions are related to incontinence.
Coital incontinence (CI) is urinary leakage that occurs during either penetration or orgasm and can occur with a sexual partner or with masturbation. It has been reported to occur in 10% to 24% of sexually active women with pelvic floor disorders.
In men
Men tend to experience incontinence less often than women, and the structure of the male urinary tract accounts for this difference. It is common with prostate cancer treatments. Both women and men can become incontinent from neurologic injury, congenital defects, strokes, multiple sclerosis, and physical problems associated with aging.
While urinary incontinence affects older men more often than younger men, the onset of incontinence can happen at any age. Recent estimates by the National Institutes of Health (NIH) suggest that 17 percent of men over age 60, an estimated 600,000 men, experience urinary incontinence, with this percentage increasing with age. Incontinence is treatable and often curable at all ages.
Incontinence in men usually occurs because of problems with muscles that help to hold or release urine. The body stores urine—water and wastes removed by the kidneys—in the urinary bladder, a balloon-like organ. The bladder connects to the urethra, the tube through which urine leaves the body.
During urination, Detrusor muscles in the wall of the bladder contract, forcing urine out of the bladder and into the urethra. At the same time, sphincter muscles surrounding the urethra relax, letting urine pass out of the body. Incontinence will occur if the bladder muscles suddenly contract or muscles surrounding the urethra suddenly relax.
Urinary Incontinence Nursing Care Plan
| Assessment | Assessment for urinary incontinence includes the number of times and frequency of micturation, characteristics of urine.
For patients who are using diapers or incontinent pads, it should be weigh to measure the amount of urine. For patients with indwelling catheter, hourly measurement is a must to calculate properly. Rogers (2008), specified that history taking, physical examination, voiding diary, urinalysis and culture, post-void residual urine volume (ultrasound or catheterization), urodynamic testing, pelvic musculature examination and cough stress test are the important data to evaluate urinary incontinence. Kessler (2008), emphasized the importance of bladder diary as a useful tool in the diagnosis of this condition. He affirmed that history-taking is the cornerstone of urinary incontinence assessment wherein the patient is instructed to record the times of voiding, voided volumes,incontinence episodes, pad usage, degree of urgency, physical exercise during urinary leakage and the degree of incontinence. |
| NursingDiagnoses* |
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| Planning | The major goals for the patient may include control of urinary incontinence, promote regular urinary elimination patterns and prevent complications. |
| Implementation |
Promoting urinary continence:
Managing patient with altered thought process:
Promoting hygiene, skin care and preventing infection:
Provision of comfort:
Promoting role performance, promoting body image and relieving anxiety and stress:
Maintaining hydration:
Promoting sleep and rest:
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| Evaluation |
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Treatment
The treatment options range from conservative treatment, behavior management, medications and surgery.The success of treatment depends on the correct diagnoses in the first place.
Physical Therapy
Physical therapy is commonly used as a conservative, early-stage treatment for urinary incontinence. Pelvic floor muscle training, otherwise known as Kegel exercises, has been shown to significantly increase pelvic muscle strength and decrease severity of urinary incontinence in adults and in children, regardless of gender.
Medications
A number of medications exist to treat incontinence including: fesoterodine, tolterodine and oxybutynin.While a number appear to have a small benefit, the risk of side effects are a concern.
Devices
Absorbent pads and various types of urinary catheters may help those individuals who continue to experience incontinence.Some absorbent pads are not bulky like many older types were, but are close fitting underwear with liners.
Absorbent products include shields, undergarments, protective underwear, briefs, diapers, adult diapers and underpads. Absorbent products are associated with leaks, odors, skin breaksown and UTI.
Men also can use an external urine collection device that is worn around the penis. There are two principal types. The traditional type is referred to as a condom or Texas catheter. These are not appropriate for men who are uncircumcised, have large or small anatomy or those who are have retracted anatomy. Condom catheter users frequently experience complications including urinary tract infections and skin breakdown. A recent innovation is the Men’s Liberty that attaches only to the tip of the penis with safe hydrocolloid adhesive and works with all types and sizes of male anatomy. There has not been a confirmed UTI or serious skin injury caused by Men’s Liberty.
Hospitals often use some type of incontinence pad, a small but highly absorbent sheet placed beneath the patient, to deal with incontinence or other unexpected discharges of bodily fluid. These pads are especially useful when it is not practical for the patient to wear a diaper.
The most common form of urine management in hospitals is indwelling or Foley catheters. These catheters may cause infection and other associated secondary complications.
In children
Urination, or voiding, is a complex activity. The bladder is a balloonlike muscle that lies in the lowest part of the abdomen. The bladder stores urine, then releases it through the urethra, the canal that carries urine to the outside of the body. Controlling this activity involves nerves, muscles, the spinal cord and the brain.
The bladder is made of two types of muscles: the detrusor, a muscular sac that stores urine and squeezes to empty, and the sphincter, a circular group of muscles at the bottom or neck of the bladder that automatically stay contracted to hold the urine in and automatically relax when the detrusor contracts to let the urine into the urethra. A third group of muscles below the bladder (pelvic floor muscles) can contract to keep urine back.
A baby’s bladder fills to a set point, then automatically contracts and empties. As the child gets older, the nervous system develops. The child’s brain begins to get messages from the filling bladder and begins to send messages to the bladder to keep it from automatically emptying until the child decides it is the time and place to void.
Failures in this control mechanism result in incontinence. Reasons for this failure range from the simple to the complex.
Incontinence happens less often after age 5: About 10 percent of 5-year-olds, 5 percent of 10-year-olds, and 1 percent of 18-year-olds experience episodes of incontinence. It is twice as common in girls as in boys.
Nursing Care Plan
Nursing Diagnosis
Inability of usually continent person to reach toilet in time to avoid unintentional loss of urine
Defining Characteristics: The relationship between functional limitations and urinary incontinence remains controversial (Hunskaar et al, 1999). While functional impairment clearly exacerbates the severity of urinary incontinence, the underlying factors that contribute to these functional limitations themselves contribute to abnormal lower urinary tract function and impaired continence.
Related Factors:
- Cognitive disorders (delirium, dementias, severe or profound retardation);
- neuromuscular limitations impairing mobility or dexterity;
- impaired vision;
- psychological factors;
- weakened supporting pelvic structures;
- environmental barriers to toileting.
NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
- Urinary Continence
- Urinary Elimination
Client Outcomes
- Eliminates or reduces incontinent episodes
- Eliminates or overcomes environmental barriers to toileting
- Uses adaptive equipment to reduce or eliminate incontinence related to impaired mobility or dexterity
- Uses portable urinary collection devices or urine containment devices when access to the toilet is not feasible
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
- Urinary Incontinence Care
Nursing Interventions
- Perform a focused history of the incontinence including duration, frequency and severity of leakage episodes, and alleviating and aggravating factors.
- Rationale: The history provides clues to the causes, the severity of the condition, and its management.
- Complete a bladder log of diurnal and nocturnal urine elimination patterns and patterns of urinary leakage.
- Rationale: The bladder log provides a more objective verification of urine elimination patterns as compared with the history (Resnick et al, 1994) and a baseline against which the results of management can be evaluated.
- Assess client for potentially reversible causes of acute/transient urinary incontinence (e.g., urinary tract infection [UTI], atrophic urethritis, constipation or impaction, sedatives or narcotics interfering with the ability to reach the toilet in a timely fashion, antidepressants or psychotropic medications interfering with efficient detrusor contractions, parasympatholytics, alpha adrenergic antagonists, polyuria caused by uncontrolled diabetes mellitus, or insipidus).
- Rationale: Transient or acute incontinence can be eliminated by reversing the underlying cause (Urinary Incontinence Guideline Panel, 1996).
- Assess client for established/chronic incontinence: stress urinary incontinence, urge urinary incontinence, reflex, or extraurethral (“total”) urinary incontinence. If present, begin treatment for these forms of urine loss.
- Rationale: Functional incontinence often coexists with another form of urinary leakage, particularly among the elderly (Gray, 1992).
- Assess the home, acute care, or long-term care environment for accessibility to toileting facilities, paying particular attention to the following: Distance of toilet from bed, chair, living quarters., Characteristics of the bed, including presence of side rails and distance of bed from the floor., Characteristics of the pathway to the toilet, including barriers such as stairs, loose rugs on the floor, and inadequate lighting.,Characteristics of the bathroom, including patterns of use; lighting; height of toilet from floor; presence of hand rails to assist transfers to toilet; and breadth of door and its accessibility for wheelchair, walker, or other assistive device
- Rationale: Functional continence requires access to the toilet; environmental barriers blocking this access can produce functional incontinence (Wells, 1992).
- Assess client for mobility, including ability to rise from chair and bed; ability to transfer to toilet and ambulate; and need for physical assistive devices such as a cane, walker, or wheel chair.
- Rationale: Functional continence requires the ability to gain access to a toilet facility, either independently or with the assistance of devices to increase mobility (Jirovec, Wells, 1990; Wells, 1992).
- Assess client for dexterity, including the ability to manipulate buttons, hooks, snaps, Velcro, and zippers needed to remove clothing. Consult physical or occupational therapist to promote optimal toilet access as indicated.
- Rationale: Functional continence requires the ability to remove clothing to urinate (Maloney, Cafiero, 1999; Wells, 1992).
- Evaluate cognitive status with a NEECHAM confusion scale (Neelan et al, 1992) for acute cognitive changes, a Folstein Mini-Mental Status Examination (Folstein, Folstein, McHugh, 1975), or other tool as indicated.
- Rationale: Functional continence requires sufficient mental acuity to respond to sensory input from a filling urinary bladder by locating the toilet, moving to it, and emptying the bladder (Maloney, Cafiero, 1999; Colling et al, 1992).
- Remove environmental barriers to toileting in the acute care, long-term care or home setting. Help the client remove loose rugs from the floor and improve lighting in hallways and bathrooms.
- Provide an appropriate, safe urinary receptacle such as a 3-in-1 commode, female or male hand-held urinal, no-spill urinal, or containment device when toileting access is limited by immobility or environmental barriers.
- Rationale: These receptacles provide access to a substitute toilet and enhance the potential for functional continence (Rabin, 1998; Wells, 1992).
- Assist the client with limited mobility to obtain evaluation for a physical therapist and to obtain assistive devices as indicated (Maloney, Cafiero, 1999); assist the client to select shoes with a nonskid sole to maximize traction when arising from a chair and transferring to the toilet.
- Assist the person to alter their wardrobe to maximize toileting access. Select loose-fitting clothing with stretch waist bands rather than buttoned or zippered waist; minimize buttons, snaps, and multilayered clothing; and substitute Velcro or other easily loosened systems for buttons, hooks, and zippers in existing clothing.
- Begin a prompted voiding program or patterned urge response toileting program for the elderly client with functional incontinence and dementia in the home or long-term care facility:
- Determine the frequency of current urination using an alarm system or check and change device
- Record urinary elimination and incontinent patterns on a bladder log to use as a baseline for assessment and evaluation of treatment efficacy
- Begin a prompted toileting program based on the results of this program; toileting frequency may vary from every 1.5 to 2 hours, to every 4 hours
- Praise the client when toileting occurs with prompting
- Refrain from any socialization when incontinent episodes occur; change the client and make her or him comfortable
- Rationale: Prompted voiding or patterned urge response toileting have been shown to markedly reduce or eliminate functional incontinence in selected clients in the long-term care facility and in the community setting (Colling et al, 1992; Eustice, Roe, Patterson, 2000).
Geriatric
- Institute aggressive continence management programs for the community-dwelling client in consultation with the patient and family.
- Rationale: Uncontrolled incontinence can lead to institutionalization in an elderly person who prefers to remain in a home care setting (O’Donnell et al, 1992).
- Monitor elderly clients for dehydration in the long-term care facility, acute care facility, or home.
- Rationale:Dehydration can exacerbate urine loss, produce acute confusion, and increase the risk of morbidity and morality, particularly in the frail elderly client (Colling, Owen, McCreedy, 1994).
Home Care Interventions
- Assess current strategies used to reduce urinary incontinence, including fluid intake, restriction of bladder irritants, prompted or scheduled toileting, and use of containment devices.
- Rationale: Many elders and care providers use a variety of self-management techniques to manage urinary incontinence such as fluid limitation, avoidance of social contacts, and absorptive materials that may or may not be effective for reducing urinary leakage or beneficial to general health (Johnson et al, 2000).
- Teach the family general principles of bladder health, including avoidance of bladder irritants, adequate fluid intake, and a routine schedule of toileting (refer to care plan for Impaired Urinary elimination).
- Teach prompted voiding to the family and patient with mild to moderate dementia (refer to previous description) (Colling, 1996; McDowell et al, 1994).
- Advise the patient about the advantages of using disposable or reusable insert pads, pad-pant systems, or replacement briefs specifically designed for urinary incontinence (or double urinary and fecal incontinence) as indicated. Many absorptive products used by community-dwelling elders are not designed to absorb urine, prevent odor, and protect the perineal skin. Substitution of disposable or reusable absorptive devices specifically designed to contain urine or double incontinence are more effective than household products, particularly in moderate to severe cases (Shirran, Brazelli, 2000; Gallo, Staskin, 1997).
- Assist the family with arranging care in a way that allows the patient to participate in family or favorite activities without embarrassment. Careful planning can retain the dignity and integrity of family patterns.
- Teach principles of perineal skin care, including routine cleansing following incontinent episodes, daily cleaning and drying of perineal skin, and use of moisture barriers as indicated. Routine cleansing and daily cleaning with appropriate products help maintain integrity of perineal skin and prevent secondary cutaneous infections (Fiers, Thayer, 2000).
- Refer to occupational therapy for help in obtaining assistive devices and adapting the home for optimal toilet accessibility.
- Consider use of an indwelling catheter for continuous drainage in the patient who is both homebound and bed-bound and receiving palliative or end of life care (requires physician order). An indwelling catheter may increase patient comfort, ease care provider burden, and prevent urinary incontinence in bed-bound patients receiving end of life care.
- When an indwelling catheter is in place, follow prescribed maintenance protocols for managing the catheter, drainage bag, perineal skin, and urethral meatus. Teach infection control measures adapted to the home care setting. Proper care reduces the risk of catheter-associated UTI.
Client/Family Teaching
- Work with the client, family, and their extended support systems to assist with needed changes in the environment and wardrobe and other alterations needed to maximize toileting access.
- Work with the client and family to establish a reasonable, manageable prompted voiding program using environmental and verbal cues, such as television programs, meals, and bedtime, to remind caregivers of voiding intervals.
- Teach the family to use an alarm system for toileting or to perform a check and change program and to maintain an accurate log of voiding and incontinent episodes.
