Urinary Incontinence - Dysfunctional Voiding Patterns

URINARY INCONTINENCE

More than 17 million adults in the United States are estimated to have urinary incontinence, with most of them experiencing over-active bladder syndrome, making this disorder more prevalent than diabetes or ulcer disease. Despite widespread media coverage, urinary incontinence remains underdiagnosed and underreported. Patients may be too embarrassed to seek help, causing them to ignore or conceal symptoms. Many patients resort to using ab-sorbent pads or other devices without having their condition prop-erly diagnosed and treated. Health care providers must be alert to subtle cues of urinary incontinence and stay informed about cur-rent management strategies.

The costs of care for patients with urinary incontinence are not limited to the dollars spent for absorbent products, medications, and surgical or nonsurgical treatment modalities. The psycho-social costs of urinary incontinence are also significant: embar-rassment, loss of self-esteem, and social isolation are common outcomes. Urinary incontinence in elderly patients often decreases their ability to maintain an independent lifestyle. This increases dependence on caregivers and often leads to institutionalization.

Urinary incontinence affects people of all ages but is particu-larly common among the elderly. It has been reported that more than half of all nursing home residents have urinary incontinence. Although urinary incontinence is not a normal consequence of aging, age-related changes in the urinary tract predispose the older person to incontinence.

Although urinary incontinence is commonly regarded as a condition that occurs in older multiparous women, it is also com-mon in young nulliparous women, especially during vigorous high-impact activity. Age, gender, and number of vaginal deliv-eries are established risk factors (Chart 44-1); they explain, in part, the increased incidence in women. Urinary incontinence is a symptom with many possible causes.

Clinical Manifestations:Types of Incontinence

Stress incontinence is the involuntary loss of urine through anintact urethra as a result of a sudden increase in intra-abdominal pressure (sneezing, coughing, or changing position). It predomi-nately affects women who have had vaginal deliveries and is thought to be the result of decreasing ligament and pelvic floor support of the urethra and decreasing or absent estrogen levels within the urethral walls and bladder base. In men, stress incon-tinence is often experienced after a radical prostatectomy for prostate cancer because of the loss of urethral compression that the prostate had supplied before the surgery, and possibly blad-der wall irritability (Reilly, 2001; Sueppel et al., 2001) (see Nursing Research Profile 44-1).

Urge incontinence is the involuntary loss of urine associatedwith a strong urge to void that cannot be suppressed. The patient is aware of the need to void but is unable to reach a toilet in time. An uninhibited detrusor contraction is the precipitating factor. This can occur in a patient with neurologic dysfunction that im-pairs inhibition of bladder contraction or in a patient without overt neurologic dysfunction (Chancellor, 1999).

Reflex incontinence is the involuntary loss of urine due tohyperreflexia in the absence of normal sensations usually associated with voiding. This commonly occurs in patients with spinal cord injury because they have neither neurologically mediated motor control of the detrusor nor sensory awareness of the need to void.

Overflow incontinence is the involuntary loss of urine asso-ciated with overdistention of the bladder. Such overdistention results from the bladder’s inability to empty normally, despite fre-quent urine loss. Both neurologic abnormalities (eg, spinal cord lesions) and factors that obstruct the outflow of urine (eg, tumors, strictures, and prostatic hyperplasia) can cause overflow inconti-nence (Reilly, 2001).

Functional incontinence refers to those instances in which lower urinary tract function is intact but other factors, such as se-vere cognitive impairment (eg, Alzheimer’s dementia), make it difficult for the patient to identify the need to void or physical impairments make it difficult or impossible for the patient to reach the toilet in time for voiding.

Iatrogenic incontinence refers to the involuntary loss of urine due to extrinsic medical factors, predominantly medications. One such example is the use of alpha-adrenergic agents to lower blood pressure. In some individuals with an intact urinary system, these agents adversely affect the alpha receptors responsible for bladder neck closing pressure; the bladder neck relaxes to the point of in-continence with a minimal increase in intra-abdominal pressure, thus mimicking stress incontinence. As soon as the medication is discontinued, the apparent incontinence resolves (Reilly, 2001).

Some patients have several types of urinary incontinence. This mixed incontinence is usually a combination of stress and urge incontinence.

Only with appropriate recognition of the problem, assess-ment, and referral for diagnostic evaluation and treatment can the outcome of incontinence be determined. All people with incon-tinence should be considered for evaluation and treatment.

Assessment and Diagnostic Findings

Once incontinence is recognized, a thorough history is necessary. This includes a detailed description of the problem and a history of medication use. The patient’s voiding history, a diary of fluid intake and output, and bedside tests (ie, residual urine, stress maneuvers) may be used to help determine the type of urinary incontinence involved. Extensive urodynamic tests may be per-formed;. Urinalysis and urine culture are per-formed to identify hematuria (from infection, cancer, or a kidney stone), glycosuria (causes polyuria), pyuria, and bacteriuria (bacteria in the urine), all of which may identify transient causes of urinary incontinence.

Management depends on the type of urinary incontinence and its causes. Urinary incontinence may be transient or re-versible (Chart 44-2), provided that the underlying cause is suc-cessfully treated and the voiding pattern reverts to normal. Management of urinary incontinence not considered transient or reversible falls into three categories: pharmacologic, surgical, and behavioral.

Gerontologic Considerations

Many older individuals experience transient episodes of inconti-nence that tend to be abrupt in onset. When this occurs, the nurse should question the patient, as well as the family if possi-ble, about the onset of symptoms and any signs or symptoms of a change in other organ systems.

Acute urinary tract infection, infection elsewhere in the body, constipation, decreased fluid intake, a change in a chronic disease pattern, such as elevated blood glucose levels in patients with di-abetes or decreased estrogen levels in menopausal women, can provoke the onset of urinary incontinence. If the cause is identi-fied and modified or eliminated early at the onset of inconti-nence, the incontinence itself may be eliminated. Although the older bladder is more vulnerable to unstable detrusor activity, age alone is not a risk factor for urinary incontinence (Suchinski et al., 1999).

Medical Management

Treatment of urinary incontinence depends on the underlying cause. Before appropriate treatment can be initiated, however, the problem and the cause must be identified.

BEHAVIORAL THERAPY

Behavioral therapies are always the first choice to decrease or eliminate urinary incontinence. In using these techniques, clini-cians help patients avoid potential adverse effects of pharmaco-logic or surgical interventions (AHCPR, 1996; Roberts, 2001) (Chart 44-3).

PHARMACOLOGIC THERAPY

Pharmacologic therapy works best when used as an adjunct to behavioral interventions. Anticholinergic agents (oxybutynin [Ditropan], dicyclomine [Antispas]) inhibit bladder contraction and are considered first-line medications for urge incontinence. Several tricyclic antidepressant medications (imipramine, dox-epin, desipramine, and nortriptyline) also decrease bladder contractions as well as increase bladder neck resistance. Stress in-continence may be treated using pseudoephedrine (eg, Sudafed). Estrogen (taken orally, transdermally, or topically) has been shown to be beneficial for all types of urinary incontinence. Es-trogen decreases obstruction to urine flow by restoring the mu-cosal, vascular, and muscular integrity of the urethra.

Gerontologic Considerations

Elderly individuals may experience cognitive decline when taking short-acting anticholinergic medications. The long-acting forms of anticholinergic medications such as oxybutynin (Ditropan XL) and tolterodine (Detrol LA) have a significantly lower inci-dence of adverse effects in all populations, including the elderly (Roberts, 2001).

SURGICAL MANAGEMENT

Surgical correction may be indicated in patients who have not achieved continence using behavioral and pharmacologic ther-apy. Surgical options vary according to the underlying anatomy and the physiologic problem. Most procedures involve lifting and stabilizing the bladder or urethra to restore the normal urethro-vesical angle or to lengthen the urethra.

Women with stress incontinence may have an anterior vagi-nal repair, retropubic suspension, or needle suspension to reposition the urethra. Procedures to compress the urethra and increase resistance to urine flow include sling procedures and placement of periurethral bulking agents such as artificial collagen.

Periurethral bulking is a semipermanent procedure in which small amounts of artificial collagen are placed within the walls of the urethra to enhance the closing pressure of the urethra. This procedure takes only 10 to 20 minutes and may be performed under local anesthesia or moderate sedation. A cystoscope is in-serted into the urethra. An instrument is inserted through the cys-toscope to deliver a small amount of collagen into the urethral wall at locations selected by the urologist. The patient is usually discharged home after voiding. There are no restrictions follow-ing the procedure, although occasionally more than one collagen bulking session may be necessary if the initial procedure did not halt the stress urinary incontinence. Collagen placement any-where in the body is considered semipermanent because its dura-bility averages between 12 and 24 months, until the body absorbs the material. Periurethral bulking with collagen offers an alterna-tive to surgery, as in a frail, elderly individual. It is also an option for individuals who are seeking help with stress urinary inconti-nence who prefer to avoid surgery and who do not have access to biofeedback and electrical stimulation.

A modified artificial sphincter that uses a silicone-rubber balloon as a self-regulating pressure mechanism can be used to close the urethra. Electronic stimulation of the pelvic floor by means of a miniature pulse generator with electrodes mounted on an intra-anal plug is another method of controlling stress in-continence.

Men with overflow and stress incontinence may undergo a transurethral resection to relieve symptoms of prostatic enlarge-ment. An artificial sphincter can be used after prostatic surgery for sphincter incompetence (Fig. 44-1). After surgery, peri-urethral bulking agents can be injected into the periurethral area to increase compression of the urethra.

Nursing Management

Nursing management is based on the premise that incontinence is not inevitable with illness or aging and that it is often reversible and treatable. The nursing interventions are determined in part by the type of treatment that is undertaken. For behavioral ther-apy to be effective, the nurse must provide support and encour-agement, because it is easy for the patient to become discouraged if therapy does not quickly improve the level of continence. Pa-tient teaching regarding the bladder program is important and should be provided verbally and in writing (Chart 44-4). The pa-tient is assisted to develop and use a log or diary to record timing of Kegel exercises, changes in bladder function with treatment, and episodes of incontinence.

If pharmacologic treatment is used, its purpose is explained to the patient and family. If surgical correction is undertaken, the procedure and its desired outcomes are described to the patient and family. Follow-up contact with the patient enables the nurse to answer the patient’s questions and to provide reinforcement and encouragement. Patients who have mixed incontinence (both stress and urge incontinence) need to understand that anticholinergic and antispasmodic agents can help decrease urinary urgency and frequency and urge incontinence, but they do not decrease the urinary incontinence related to stress incontinence.