Urinary Incontinence Management

In elderly patients, incontinence commonly follows any loss or impairment of urinary or anal sphincter control. The incontinence may be transient or permanent. In all, about 10 million adults experience some form of urinary incontinence; this includes about 50% of the 1.5 million people in extended-care facilities. Fecal incontinence affects up to 10% of the patients in such facilities.

Contrary to popular opinion, urinary incontinence is neither a disease nor a part of normal aging. Incontinence may be caused by confusion, dehydration, fecal impaction, or restricted mobility. It's also a sign of various disorders, such as prostatic hyperplasia, bladder calculus, bladder cancer,

urinary tract infection (UTI), stroke, diabetic neuropathy, Guillain-Barrè syndrome, multiple sclerosis, prostatic cancer, prostatitis, spinal cord injury, and urethral stricture. It may also result from urethral sphincter damage after prostatectomy. In addition, certain drugs, including diuretics, hypnotics, sedatives, anticholinergics, antihypertensives, and alpha antagonists, may trigger urinary incontinence.

Urinary incontinence is classified as acute or chronic. Acute urinary incontinence results from disorders that are potentially reversible, such as delirium, dehydration, urine retention, restricted mobility, fecal impaction, infection or inflammation, drug reactions, and polyuria. Chronic urinary incontinence occurs as four distinct types: stress, overflow, urge, and functional incontinence.

In stress incontinence, leakage results from a sudden physical strain, such as a sneeze, cough, or quick movement. In overflow incontinence, urine retention causes dribbling because the distended bladder can't contract strongly enough to force a urine stream. In urge incontinence, the patient can't control the impulse to urinate. Finally, in functional (total) incontinence, urine leakage occurs despite the fact that the bladder and urethra are functioning normally. This condition is usually related to cognitive or mobility factors.

Equipment

Bladder retraining record sheet ; gloves; stethoscope (to assess bowel sounds) ; lubricant ; moisture barrier cream ; antidiarrheal or laxative suppository ; incontinence pads ; bedpan ; specimen container ; label ; laboratory request form ; optional: stool collection kit, urinary catheter.

Implementation

Whether the patient reports urinary or fecal incontinence or both, you'll need to perform initial and continuing assessments to plan effective interventions.

For urinary incontinence

• Ask the patient when he first noticed urine leakage and whether it began suddenly or gradually. Have him describe his typical urinary pattern: Does he usually experience incontinence during the day or at night? Does he get the urge to go again immediately after emptying the bladder? Does he get strong urges to go? Ask him to rate his urinary control: Does he have moderate control, or is he completely incontinent? If he sometimes urinates with control, ask him to identify when and how much he usually urinates.
• Evaluate related problems, such as urinary hesitancy, frequency, urgency, nocturia, and decreased force or interrupted urine stream. Ask the patient to describe any previous treatment he has had for incontinence or measures he has performed by himself. Ask about medications, including nonprescription drugs.
• Assess the patient's environment. Is a toilet or commode readily available, and how long does the patient take to reach it? After the patient is in the bathroom, assess his manual dexterity; for example, how easily does he manipulate his clothes?
• Evaluate the patient's mental status and cognitive function.
• Quantify the patient's normal daily fluid intake.
• Review the patient's medication and diet history for drugs and foods that affect digestion and elimination.
• Review or obtain the patient's medical history, noting especially the number and route of births, hysterectomy (in women), and any incidence of UTI, prostate disorders, diabetes, spinal injury or tumor, stroke, and bladder, prostate, or pelvic surgery. Assess for such disorders as delirium, dehydration, urine retention, restricted mobility, fecal impaction, infection, inflammation, and polyuria.
• Inspect the urethral meatus for obvious inflammation or anatomic defects. Have the female patient bear down while you note any urine leakage. Gently palpate the abdomen for bladder distention, which signals urine retention. Assess for costovertebral angle tenderness. If possible, have the patient examined by a urologist.

• Obtain specimens for appropriate laboratory tests as ordered. Label each specimen container, and send it to the laboratory with a request form.
• Begin incontinence management by implementing an appropriate bladder retraining program.
• Nursing alert Obtain a 24- to 48-hour bladder diary before implementing bladder retraining.
• To ensure healthful hydration and to prevent UTI, make sure the patient maintains an adequate daily intake of fluids (six to eight 8-oz glasses). Restrict fluid intake after 6 p.m.
• To manage stress incontinence, begin an exercise program to help strengthen the pelvic floor muscles. (See Strengthening pelvic floor muscles.)
• To manage functional incontinence, frequently assess the patient's mental and functional status. Regularly remind him to void. Respond to his calls promptly, and help him get to the bathroom quickly. Provide positive reinforcement.
   

Complications

Skin breakdown and infection may result from incontinence. Psychological problems resulting from incontinence include social isolation, loss of independence, lowered self-esteem, and depression.

Documentation

Record all bladder and bowel retraining efforts, noting scheduled bathroom times, food and fluid intake, and elimination amounts, as appropriate. Document the duration of continent periods. Note any complications, including emotional problems and signs of skin breakdown and infection as well as the treatments given for them.