In
this era of rapid, scientific medical advances, we still live
with the myth that urinary incontinence should be accepted as
a normal part of aging. Urinary Incontinence, however, should
not be considered a disease but rather a symptom or sign of an
underlying problem.
Patients with urinary Incontinence now have places to turn to
for advice and medical treatment. In addition to urologists, gynecologists,
and geriatricians, nurses are actively involved in the evaluation
and management of patients with urinary Incontinence. The purpose
of this article is to outline a systematic nursing approach to
the evaluation, diagnosis, and treatment with urinary Incontinence
in and office setting.
Assessment
of Urinary Incontinence
Urinary
incontinence in the involuntary loss of urine per the urethra.
Urinary incontinence may be caused by many variables. Some cases
are easily diagnosed with a complete history and physical exam,
while others require complex testing to determine the cause. However,
urinary incontinence should not be considered a disease, but rather
a symptom or sign of lower urinary tract dysfunction (6). Incontinence
may result from a loss of bladder control or a lack of motivation
or ability to perform toileting functions. Nocturia, urinary frequency,
or urgency without actual urinary loss may also signal an underlying
organic condition. Such conditions could be a bladder stone, bladder
tumor or obstruction, which create symptoms of irritative voiding
and therefore cause urinary frequency. Many patients will benefit
from a urologic consultation. This consultation may include but
not being limited to diagnosis, evaluation, and treatment options
available to the incontinent patient. Some simple, commonly used,
cost-effective evaluation tools and treatment options for urinary
incontinent patients will be discussed for use in the office setting.
Conclusion
All
clinicians need to take an active role in the evaluation, diagnosis,
and treatment of urinary incontinence. The firs step is as simple
as asking the patient if he or she is experiencing urine loss.
Assessment and evaluation of urinary incontinence is the second
step in helping the patient. A complete history and physical assessment
along with some simple diagnostic tools can help the practitioner
determine the correct diagnosis. Finally, appropriate interventions
ranging from conservative to more sophisticated should be explored
by the clinician with the patient.
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Mrs.
K is a 55-year-old woman who comes to the Continence Center complaining
that she loses urine whenever she coughs. She states that she
needs to wear a panty liner every day, because she is not always
sure when she may have an accident. The patient voices that she
is afraid that the problem might get worse, and she asks if anything
can be done to improve her situation. In assessing Mrs. K, the
clinician obtained more detailed information, specifically about
her incontinence: When did you first notice the incontinence?
How often do you need to change your pad? Do you have to get up
at night to urinate? Are there certain activities which cause
you to lose urine? Additionally, questions were asked that differentiated
stress urinary incontinence from urge incontinence.
A
complete past medical history reveals Mrs. K. has a history of
bronchial asthma that has been particularly bothersome over the
past month. She denies any history of diabetes, back injury, cardiac
disease, cancer, or neurologic problems, such as multiple sclerosis,
Parkinson's, or stroke. Patient has regular bowel movements every
day. Mrs. K. is a grava 3. para 3. All her children were vaginal
deliveries without complications. Mrs. K. denied having had any
surgical procedures. Medications include Proventil inhaler 2 puffs
prn, Premarin, and Provera. Mrs. K. has no known drug allergies.
She is a nonsmoker and occasionally drinks I to 2 alcoholic drinks
per week.
The findings from Mrs. K.'s physical exam showed a poorly supported
bladder, negative rectocele, negative cystocele. The Marshall
test was positive for stress incontinence. From the physical assessment
and history, a diagnosis of stress urinary incontinence was made.
The clinician suggested to Mrs. K. that conservative interventions.
such as biofeedback therapy and behavior modification be initiated
to treat the incontinence. The plan for Mrs. K. included having
her complete a 3-day voiding diary, obtaining a urine sample for
culture, and beginning a biofeedback therapy program.
At
the second meeting, changes from the previous meeting and the
bladder diary were reviewed. The patient was taught about the
anatomy and physiology of stress urinary incontinence. Pictures,
drawings and models were particularly helpful in explaining how
incontinence occurs. Once the patient grasped an understanding
of this pathophysioiogy, the clinician began discussing the role
of pelvic floor exercises in controlling urinary incontinence.
Mrs. K.'s treatment program consisted of using a biofeedback home
unit twice a day. The unit was programmed by the practitioner
to allow the patient to practice exercises at home with the visual
and auditory aid of the biofeedback unit. The unit was programmed
for the length of time for an exercise session, work and rest
periods, and goals for the patient to achieve. Once the parameters
were determined, the patient only had to turn on the unit: insert
the biofeedback monitor, either a vaginal or rectal probe: and
begin exercising. Mrs. K. was willing and able to use the unit
properly. She was asked to follow up at the center in 1 week with
the home unit in order to download the exercise sessions that
the patient had done at home and to answer any questions. At this
visit, the practitioner evaluated how often the patient used the
unit, whether goals have been reached, and whether settings on
the unit need to be changed. The patient is then followed up monthly.
In
1 month, Mrs. K. was able to meet the goals established and was
using the unit twice a day. More important, Mrs. K. was noticing
subtle changes in her bladder control. She commented "the other
day I was able to sneeze without losing any urine." The settings
on her home unit were reprogrammed and within 2 months she noticed
significant improvement.
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Miss
V. is a 28-year-old female who came to the Continence Center with
complaints of urinary urgency and frequency. She has had the problem
for 2 years. During our interview she said that she had gone to
the bathroom four times in the past hour. Miss V. further explained
that she gets up one to two times during the night to urinate,
and that on a rare occasion she wets the bed sheets. She stated
that she wears a panty liner every day because sometimes she cannot
make it to the bathroom without being incontinent.
Miss
V.'s past medical history was negative for multiple sclerosis,
spinal cord disease, injury, or surgery. She also denied having
had any bladder surgery, kidney stones, or pelvic surgeries and
stated that to her knowledge she had never had a urinary tract
infection. She further denied any medication, food, or environmental
allergies. She stated that she does not have glaucoma or any gastrointestinal
disorders. She was not taking any medications at the time of the
interview.
Miss
V. was straight catheterized for a post void residual of 20 cc.
The urine was clear and without odor; however, a specimen was
sent for urine culture to rule out a urinary tract infection.
Since her post void residual was minimal, a differential diagnosis
of overflow incontinence that may present with signs of urgency
and frequency was ruled out. Based upon her presenting symptoms
and negative history, she was diagnosed with urge incontinence.
Miss
V. was seen again 1 week later at the Continence Center to discuss
the options for treating her urinary urgency and frequency. It
was explained to her that biofeedback therapy with behavior modification
would decrease the incidence of incontinence.
The
exercise component of the program consists of the strengthening
of the pelvic floor muscles in order to inhibit bladder contractions
and decrease urinary frequency. The exercises are effective because
they help to increase the strength and tone of the sphincter muscle.
In addition, contraction of the pelvic floor muscles inhibits
detrusor muscle contractility. This is a reflex response to pelvic
floor muscle contraction [5]. When the patient experiences an
urge, he or she is instructed to contract the pelvic floor muscle
for 1 to 2 seconds and then relax. With practice, the patient
is able to hold the urine until he or she is able to get to the
bathroom.
The
patient is instructed to squeeze the pelvic floor muscle for ten
seconds and then relax the muscle for ten seconds. The patient
is taught the proper method of doing the exercises by use of a
biofeedback computer. This computer measures the effectiveness
of the pelvic floor muscle contraction and, more important, provides
feedback to the patient as to the strength and endurance of their
muscles. The patient is instructed to practice the exercises two
times per day for 10-minute periods. An audiocassette tape is
also given to the patient to increase her compliance with the
exercise program.
In
conjunction with the exercises, the patient should also keep a
voiding journal. The patient would document her daily fluid intake
and the time and amount of urine with respect to each void. This
process increases the patient's awareness of how often she is
actually urinating. Patients are also asked to try to delay each
time they need to urinate by 5 minutes. Once a patient has mastered
this goal, they are asked to increase the time to a 10-minute
interval the following week. This is challenging for the patient
who urinates with the slightest urge. Usually within 1 month,
a motivated patient can suppress an urge to void for up to 25
minutes.
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Mr.
W. is a 62-year-old married man who was found to have a hard palpable
prostate nodule upon rectal exam during his annual physical. A
prostate specific antigen (PSA) blood test was obtained and a
needle biopsy that confirmed the diagnosis of prostate cancer,
After consultations with a urologist and radiologist, Mr. W. decided
to have a radical retropubic prostatectomy instead of radiation
therapy. He underwent the radical retropubic prostatectomy without
complications and was discharged from the hospital on post-operative
day 5. His catheter was removed 9 days after surgery, at which
time Mr. W. started to experience large volumes of urinary incontinence
during activities such as walking, arising from a chair, bending,
and coughing. Mr. W. was informed by his urologist that urinary
incontinence was an expected short-term outcome following radical
prostatectomy surgery. However, Mr. W. was not informed about
the severity or duration of urinary incontinence.
Mr.
W. was very distressed by his urinary incontinence. He was changing
a large, bulky diaper 4 to 5 times a day to prevent his clothes
from becoming wet with urine. Although he was feeling physically
stronger and wanted to return to work as a computer technician,
he was very concerned about being in public for fear that someone
would smell his wet diaper or notice his urinary incontinence
on his clothes. When Mr. W. returned to the urologist for a routine
follow-up visit 6 weeks after surgery, he discussed his concerns
about urinary incontinence and expressed a desire to -get help.'
Mr. W. was then referred to the Continence Center for evaluation
and treatment.
At
initial evaluation by the nurse in the Continence Center, the
patient reported no urinary incontinence prior to his radical
prostatectomy. He denied urinary urgency or frequency, and stated,
'the urine just comes out in squirts when I walk, and I don't
even get the urge to go to the bathroom.' He described being 'mostly
dry at night when asleep, or when sitting in a recliner to watch
the evening news.' He was otherwise 'healthy,' had no medical
problems. never had surgery prior to the radical prostatectomy,
and did not take any medications.
Mr.
W. was educated by the nurse about the location, function, and
contraction of his pelvic floor muscles using a diagram (see Figure
3B). By increasing the tone and support of his pubococcygeal muscles,
he would increase his external sphincter tone, and hence improve
his urinary control. He was instructed via the nurse and a biofeedback
computer system in proper identification of his pubococcygeal
muscles. Using a small rectal 'suppository like' probe to monitor
Mr. W.'s ability to isolate his pubococcygeal muscles without
overcompensating with abdominal muscles, he quickly and consistently
demonstrated proper pelvic floor muscle identification and contraction.
He was instructed in slow twitch pelvic floor muscle exercise
contractions. holding for 10 seconds then relaxing for 10 seconds,
to build endurance of his pubococcygeal muscles. Through the use
of the biofeedback color computer system, Mr. W. was able to monitor
when he was properly contracting his pubococcygeal muscles. This
reinforcement provided the patient with confidence that he would
be able to perform these exercises at home.
Mr.
W. was given an audiocassette tape to 'coach' him through pelvic
floor exercises at home for 10 minutes twice a day for 1 month.
When he returned to the Continence Center approximately 1 month
after the initial visit, he was markedly improved. changing an
incontinence shield two times a day, noting only feeling 'damp,'
and expressing being very happy with his progress. He described
being very faithful to doing his pelvic floor exercises twice
daily in efforts to improve his urinary control. At this visit,
biofeedback was performed to reinforce Mr. W of his increased
pelvic floor strength, and also assist him in starting fast-twitch
pelvic floor exercises.
Fast-twitch
exercises are done by contracting the pubococcygeal muscle for
a second then relaxing the muscle for a second. These exercises
are performed consecutively 10 times, then relaxed for 10 seconds,
for a total of 3 minutes. By doing a combination of slow-twitch
and fast-twitch muscle fiber exercises the pubococcygeal muscle
is strengthened and speed is increased when these muscles are
contracted with expected urinary incontinence. Mr. W. was instructed
to continue his slow twitch pelvic floor exercises for 10 minutes
twice a day, and to add 3 minutes of fast twitch exercises twice
a day to his exercise regime.
When
Mr. W. returned to the Continence Center 6 weeks later, he was
very happy about his urinary improvement. He was wearing a panty
shield for 'safety,' but described 'being dry most of the time.'
He was instructed to continue his pelvic floor exercises as previously
instructed for 3 months, then follow up for another evaluation.
Mr.
W. is a very "typical" patient s/p radical prostatectomy who experienced
urinary incontinence. Most met s/p prostatectomy are very motivated
and eager to be proactive in their care: they will do almost any
form of exercise in an attempt to regain continence. Educating
and supporting the patient about urinary incontinence as an expected
outcome is very important in postoperative care. If this education
is not provided, the patient may become frustrated and depressed
with the lack of progress regarding bladder control. Ensuring
that the patient can perform proper pelvic floor identification
and contraction, and offering a treatment regimen provides the
patient with structure in a positive manner. In addition, by discussing
urinary incontinence openly with the patient. a rapport will be
established with the health care provider that encourages the
patient to gain emotional support and education in a non threatening
manner.
About
the Authors
Mimi Gallo, BS, RN, is a coordinator at the Urodynamics
& Continence Center at Beth Israel Hospital, Boston, and Mass.
Pamela
J. Fallon, BS, RN, is a coordinator at the Urodynamics & Continence
Center at Beth Israel Hospital, Boston, and Mass.
David
R. Staskin, MD, is an assistant professor at Harvard Medical
School and a Director at the Urodynamics & Continence Center at
Beth Israel Hospital, Boston, Mass.
