Abstracts from: Urinary Incontinence: Steps to Evaluation,
Diagnosis, and Treatment
By: Mimi L. Gallo, B.S., R.N 
Pamela J. Fallon, B.S., R.N.
David R. Staskin, M.D

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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Case Study I

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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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Case Study II

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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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Case Study III

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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.