Chapter 15:Urinary Incontinence

Learning Objectives

• Describe the prevalence of urinary incontinence among older adults in community, acute care, and long-term care settings.

• Identify the negative social, psychological, physical, and economic implications of urinary incontinence.

• Understand that urinary incontinence is not a normal part of aging.

Learning Objectives (cont’d)

• Collect the appropriate data related to patients’ urine control and plan evidence-based nursing care accordingly.

• Initiate evidence-based behavioral interventions to treat urinary incontinence and promote continence for those at risk for urinary incontinence.

Prevalence• Estimates vary widely due to differences in

definition, population studied, sampling approaches, and data collection methods– Total population with UI: 10%– Long-term care residents: up to 70%

• Older women: 30% - 50%• Older men: 9% - 28%

• Not normal consequence of aging but some physiological changes of aging increase risk of UI and some conditions that predispose UI occur more in older persons

Implications of Urinary Incontinence• Physical

– Incontinence is associated with an increased risk of falls, fractures, skin breakdown, UTIs, disrupted sleep

• Psychological (Figure 15-1, p. 548)– Depression and anxiety both cause and

consequence– Feelings of loss of control, dependency, shame and

guilt, impaired self esteem– Majority of UI people do not seek help because

they consider it a normal part of aging

Implications of Urinary Incontinence (cont’d)

• Social– Social isolation, avoidance of activities

• Economic– Costs not covered by insurance– Direct costs of UI: $16 billion/year– Costs to nursing homes: $5.2 billion/year

• Estimated 3% - 8% of nursing home costs and 1hr labor per day go to incontinence care

• Plus costs of medical effects like falls, fractures, pressure ulcers

Assessment

• Transient Urinary Incontinence– caused by onset of an acute problem and should

resolve once problem is successfully treated (P.551, Table 15-2).

• Established Urinary Incontinence– Stress UI– Urge UI– Overflow UI– Functional UI– Mixed UI

• Stress incontinence: involuntary loss of urine during activities that increase intra-abdominal pressure (Triggered by laughing, sneezing, coughing or straining of abdominal muscles)

– Absence of bladder contraction or over-distention.– Related to pregnancy, obesity, surgery, exercise,

medications– Small amounts urine lost– Occasional or continual episodes of incontinence– Treatment: biofeedback, Kegel exercise.

• Urge incontinence: a strong, abrupt desire to void and the inability to inhibit leakage in time to reach a toilet.– Related to birth defects, spine or nerve damage,

immobility, prostate problems or cancer– Moderate to large amounts of urine lost– Occasional or situational episodes of

incontinence– Increase risk of falls– Treatment: Kegels

• Overflow incontinence: overdistention of the bladder due to abnormal emptying.– Related to birth defects, spine or nerve damage,

MS, loss of bladder muscle tone, surgery, medications

– No warning prior to incontinent episode– Small to moderate amount of urine lost– Frequent or continual incontinence– Treatment: treat cause, intermittent cath,

bladder scans for post-void residuals

• Functional incontinence: refers to problems from factors external to the lower urinary tract such as cognitive impairments, obesity, clutter, immobility, or environmental barriers.– Related to inability to get to bathroom facilities

due to functional reasons– May be associated with urge incontinence (mixed

incontinence)– Treatment: modify environment; modify lifestyle

• Mixed incontinence: • Clinically, patients may exhibit symptoms of

more than one type of incontinence.

• Pure stress and pure urge incontinence were uncommon in a urodynamic evaluation of people age 65 years or older.

Assessment (cont’d)• Data Gathering

– History and other pertinent data– Bladder diary (Figure 15-2, P. 554)– UI Interview Instruments (Table 15-4, p. 555)– Cognitive status

• Physical AssessmentGeneralHydrationGenitourinaryRectal

AbdominalBladder VolumeUrinalysisEnvironment

Interventions and Care Strategies

• Patient-Centered Urinary Incontinence Treatment Goals– Understanding the patient’s expectations for

treatment outcomes will provide direction for intervention

– Patient goals are multidimensional; don't necessarily require total continence for patient satisfaction and improved health-related quality of life

Interventions and Care Strategies • Behavioral Management

– Prompted voiding (Table 15-7, p. 565): for the physically & cognitively impaired people.

– Bladder training (Table 15-8, p. 566): for the physically & cognitively independent people.

– Pelvic muscle rehabilitation: “draw in” and “lift up” the rectal/anal sphincter muscles. Lift up the perivaginal muscles and avoid contracting the abdominal muscles. 10 repetitions 2~3 x /day (P. 568)

Interventions and Care Strategies (cont’d)

• Pharmacological Management (Table 15-9): Oxybutynin, Imipramine, Tamsulosin…– Can add to the effectiveness of behavioral strategies

in frail older persons with urge UI– Potential for adverse reactions– Added cost

• Devices and products– Continence garments– Toileting equipment and collection devices

Interventions and Care Strategies (cont’d)

• Skin care– Preventing skin breakdown is very important– Moisture barriers– Moisture barriers & no-rinse incontinence

cleansers recommended over soap and water– Incontinence-associated dermatitis (IAD)

• Increases risk of pressure ulcers

Interventions and Care Strategies (cont’d)

• Environmental Intervention– Modifying environment to allow rapid access to

the toilet

• Indwelling urinary catheters– No longer primary means of managing UI– Centers for Medicare and Medicaid Services

(CMS) developed regulations for guidance of long-term indwelling catheter use. (Table 15-10, p. 574)

Summary

• Urinary incontinence

– is a serious, potentially disabling condition with negative social, physical, psychological, and economic impacts

– is a common condition in the older population, but is not a part of the normal aging process

– can be successfully treated for improved health-related quality of life