Urinary incontinence By Donna Scemons, PhD, FNP-BC, CNS, CWOCN
52 l Nursing2013 l November
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in adults
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URINARY INCONTINENCE (UI), the inability to voluntarily control urine loss in an adult with a history of continence, presents challenges for nurses, patients, caregivers, and the community. Although many may consider UI to be a normal part of aging or certain healthcare events, it’s normal only in infants. For adults, UI is a distressing and disabling disorder that many fail to disclose to healthcare professionals. This article reviews bladder function and discusses the four main types of UI in adults. Patient assessment and nursing interventions presented here are based on the type of UI: stress, urge, mixed, and overflow. Why is UI important? The National Institutes of Health posits that about 20 million women and 6 million men living in the community experience some type of UI in their lifetime.1 Although the epidemiology of UI hasn’t been studied in men as much as in women, generally speaking, the prevalence of UI in women is about twice that of men.2 Only 22% of men with signs and symptoms of UI seek care for UI compared with 45% of women.2 UI is much more common in people living in nursing homes than in the community, ranging from 43% to 77% in these residents. In the United States, 6% to 10% of nursing home admissions are due to UI. www.Nursing2013.com
Cognitive impairment is linked with a 1.5- to 3.5-fold increase in the risk of UI, especially when the person is more frail.1 The prevalence of UI (any leakage during the past year) in women ranges from about 25% to 50%, increasing with age. UI affects 30% to 60% of women during pregnancy. In a large representative U.S. survey of women who weren’t pregnant, moderate or severe UI (leaking more than just drops at least monthly) affected 7% of women ages 20 to 39, rising gradually to 32% for those age 80 or older. The frequency and volume (severity) of UI also increase with age.1 About half of affected women have stress incontinence, with mixed stress and urge incontinence next most common.1 As in women, UI rates increase with age in men. Among men living in the community, the prevalence of UI (defined as at least one episode in the past 12 months) increases from 4.8% in those ages 19 to 44 to 21.1% in those older than 65. In men older than 65, the prevalence of daily UI is 2% to 11%.2 Estimating types of UI in men is difficult because UI is affected by prostate disease treatment. Urge urinary incontinence is more common in men than in women, but mixed incontinence is relatively rare in men. Compared with men who don’t have UI, men with urge
incontinence are more likely to be depressed and to change their activities (for instance, work fewer hours, change jobs, or retire early).2 Direct and indirect costs of UI are estimated to be around $20 billion per year with a projected 35% increase over the next 10 years.3 These figures, based on imprecise estimates of prevalence, are higher than the known costs for patients with arthritis, pneumonia, influenza, or breast cancer.3 Considering the high incidence, prevalence, and estimated costs of UI, nurses providing all levels of care are professionally obligated to develop assessment and evaluation skills and individualized plans of care for patients who are at risk for or experiencing UI. To facilitate individual care planning through critical thinking, nurses need to review bladder function and risk factors for UI. (See Who’s at risk for UI?) Urinary bladder function The bladder’s functions are to store and then to empty urine. Controlling these functions involves the autonomic nervous system, which is involuntary, and the somatic nervous system, which is voluntary. The parasympathetic nervous system helps the bladder to empty by generating contractions of the smooth muscle of the bladder wall and relaxing the internal sphincter. The sympathetic November l Nursing2013 l 53
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
nervous system helps the bladder to fill by relaxing the smooth muscle of the bladder wall and contracting the internal sphincter. Voluntarily controlling urination and continence is the task of the striated muscles found in the external sphincter and pelvic floor. These muscles are innervated by the somatic nervous system.4,5 (See Picturing the male and female genitourinary systems.) Micturition, or the passage of urine, occurs when the detrusor muscle contracts to expel urine from the bladder. (See Close up of the bladder.) The detrusor muscle continues
into the bladder neck as circular muscles that are sometimes called the internal urethral sphincter. Extending obliquely behind the proximal urethra, they form the posterior urethra in men and the complete urethra in women. When the bladder relaxes, these muscles close, functioning as a sphincter or a shutoff valve. This sphincter is pulled open when the detrusor muscle contracts, changing the bladder’s shape. Measuring 2.5 to 3.5 cm (1 to 1.4 in) in women, the urethra is shorter than in men, where its length ranges from 16.5 to 18.5 cm (6.5 to 7.3 in).
Who’s at risk for UI?1,2,16-18 Category By gender
Those at highest risk Women are at higher risk than men, especially those who
• have given birth, especially those having their first child after age 30
• had vaginal deliveries, especially those causing pelvic prolapse*
• participate in high-impact exercises, which causes more leaking
• have had a hysterectomy • have had two or more urinary tract infections in the past 12 months. Men who’ve had prostate disease, especially with a history of prostate surgery or radiation therapy Age
• Women age 65 or older • Men age 60 or older • Risk increases with age
Neurologic conditions
• Stroke • Parkinson disease • Alzheimer disease • Spinal cord injury • Multiple sclerosis • Disc herniation • Normal pressure hydrocephalus
Other conditions
• Diabetes mellitus • Obesity • Chronic cough (chronic bronchitis, chronic obstructive pulmonary disease, asthma, smoking) • Smoke or smoked more than one pack per day • Heart failure • Diabetes insipidus • Certain cancers, such as urethral cancer
Potentially reversible factors
• Fecal impaction • Alcohol or caffeine intake • Medications, such as loop diuretics, oral contraceptives, and anticholinergics.
*No evidence shows that caesarian sections or episiotomies reduce UI.
54 l Nursing2013 l November
Women’s urethras are usually less resistant to urine outflow than men’s.5 The external sphincter is another circular muscle made up of striated muscle fibers around the urethra distal to the bladder’s base. This sphincter can stop micturition in progress and maintain continence even when bladder pressure is higher than normal. Finally, the pelvic floor’s skeletal muscle helps to support the bladder and maintain continence.6 Micturition is a two-phase cycle: the bladder-filling/storage phase and the bladder-emptying phase. Continent adults normally have voluntary control over when and where micturition occurs, including the ability to stop and start urine flow, and increase and decrease the flow rate. Normal bladder function requires coordination between the sensory and motor components of the involuntary autonomic and voluntary somatic nervous systems.5 Effects of aging The prevalence of UI increases with age.1 Although bladder capacity is about 300 to 500 mL, the urge for micturition occurs when the bladder contains about 150 to 300 mL of urine.6 Aging results in some common bladder changes, such as decreased bladder capacity and bladder elasticity, increased spontaneous detrusor contractions, and decreased ability to postpone micturition, causing more frequent voiding. Decreased detrusor muscle strength results in incomplete bladder emptying, and decreased urethral closing pressure may lead to dribbling or leaking.6,7 Main types of UI The four main types of UI are stress, urge, mixed, and overflow. Stress urinary incontinence (SUI) is described as involuntary urine leakage that occurs with activities such as laughing, coughing, sneezing, lifting, or climbing stairs. Although SUI is more common among postmenopausal women, younger women may experience it during aerobics or running www.Nursing2013.com
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
and during the week before menstruation. Premenstrual SUI may be a function of lower estrogen levels causing lower urethral muscle pressure.8 The underlying etiology of SUI is urethral hypermobility when the normal muscular supports at the urethrovesical junction fail. Underlying causes of urethral hypermobility in women include vaginal delivery, vaginal surgery, inadequate estrogen levels, pelvic radiation, trauma, certain neurogenic disorders, and advanced age.9 Intrinsic sphincter deficiency is a less common cause of SUI in women, but it should be considered when a patient experiences urinary leaking. Sphincter deficiency is more commonly seen as a result of aging, inadequate estrogen, irradiation, meningomyelocele, prior vaginal surgery, sacral cord lesions, or trauma.9 For men, SUI may result after prostatectomy when urethral sphincter nerves or muscles are damaged or from postoperative scar tissue formation. In these situations, men complain of urine leaking with coughing, sneezing, lifting, or other activities that increase intraabdominal pressure.9,10 Urge urinary incontinence is described as involuntary leakage of urine associated with a sudden strong feeling of bladder fullness and difficulty deferring micturition. The urine leakage ranges from a few drops to enough to completely soak undergarments.11 Although the exact etiology and pathology is poorly understood, the detrusor responds with involuntary overactivity during the filling phase.6 Mixed urinary incontinence is diagnosed when symptoms of SUI and urge incontinence occur together. Among middle-aged and older women, mixed urinary incontinence is the most common form of UI. Patients present with a history of urine leaking during activities that increase intraabdominal pressure and strong feelings of urgency at the same time.6 The goal of treatment is generally based on which symptoms the www.Nursing2013.com
Picturing the male and female genitourinary systems Female genitourinary system (cross-section)
Ureter (retro-peritoneal)
Ovary and fallopian tube
Uterus
Bladder
Ureteral orifice
Urethra External meatus Vagina
Rectum
Male genitourinary system (cross-section)
Ureter (retro-peritoneal) Vas deferens (retro-peritoneal)
Bladder
Trigone Prostatic urethra Prostate gland Penile urethra External meatus Rectum
patient perceives as being the worst. Conservative interventions are attempted first; if satisfactory symptom resolution isn’t achieved after a specific period, less conservative interventions such as surgery will be planned.
Overflow incontinence is continuous involuntary leakage or dribbling of urine that occurs with incomplete bladder emptying.11 Overflow incontinence affects patients with atonic or overdistended bladder, urethral obstruction, or detrusor November l Nursing2013 l 55
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
sphincter dyssynergia (DSD).12 DSD occurs when the external urethral sphincter contracts at the same time the detrusor contracts, resulting in urinary outflow obstruction such as occurs in patients with neurogenic bladder.13 Signs and symptoms include suprapubic tenderness, frequent urge to void (especially at night), incomplete emptying, a urinary stream that starts and stops or is weak or slow, nocturia, dribbling, straining, and a sense of a full bladder.
tients with urge incontinence that doesn’t respond to behavioral treatments or drugs. The healthcare provider applies an external stimulator to determine if neuromodulation works for the patient; if signs and symptoms are reduced by 50%, a surgeon will implant the device. Although neuromodulation can be effective, it’s not for everyone. The therapy is expensive and requires surgery and possibly surgical revisions and replacement.8 Vaginal devices for stress incontiTypes of treatment nence. Weak pelvic muscles can Here are some of the latest methods cause stress incontinence. A pessary for treating UI. is a stiff ring that a healthcare profesBiofeedback uses measuring sional inserts into the vagina, where devices to help patients become it presses against the wall of the vaaware of their body’s functioning. By gina and the nearby urethra. The using electronic devices or diaries to pressure helps reposition the uretrack when the bladder and urethral thra, leading to less stress leakage. muscles contract, the patient can Teach a patient using a pessary to be gain control over these muscles. alert for possible vaginal and urinary Biofeedback can supplement pelvic tract infections and see her healthmuscle exercises and electrical stimcare provider regularly.8 ulation to relieve stress and urge Injections for stress incontinence. incontinence.8,14 Various bulking agents, such as colNeuromodulation, or stimulation lagen and carbon spheres, can be inof nerves to the bladder leaving the jected near the urinary sphincter. The spine, can be effective in some pabulking agent is injected into tissues around the bladder neck and urethra to Close up of the bladder5 make the tissues thickNote the flattening of epithelial cells when the bladder er and close the bladis full and the wall is stretched. der opening to reduce Epithelium when Epithelium when stress incontinence. bladder is empty bladder is full Before the injection is given, patients may need a skin test to determine whether they could have an allergic reaction to the Detrusor muscle material. Over time, the body may slowly Ureters eliminate certain bulking agents, so the patient will need repeat injections. Scientists are testing newer Trigone agents, including paInternal sphincter tients’ own muscle cells, to see if they’re External sphincter effective in treating stress incontinence.8
58 l Nursing2013 l November
Surgery for stress incontinence. In some women, the bladder can move out of its normal position, especially following childbirth. Surgeons have developed techniques for supporting the bladder so it returns to its normal position.8 Retropubic suspension uses sutures to support the bladder neck. In the Burch procedure, the most common operation, the surgeon makes an incision in the abdomen a few inches below the navel and then secures threads to strong ligaments within the pelvis to support the urethral sphincter. This procedure is often done at the time of an abdominal procedure such as a hysterectomy.8 Sling procedures are performed through a vaginal incision. Slings may consist of natural tissue or manmade material. The traditional sling procedure uses a strip of the patient’s fascia to cradle the bladder neck. The surgeon attaches both ends of the sling to the pubic bone or ties them in front of the abdomen just above the pubic bone.8 Midurethral slings are placed in newer procedures that can be performed on an outpatient basis. These procedures use synthetic mesh materials that the surgeon places midway along the urethra. The two general types of midurethral slings are retropubic slings, such as transvaginal tapes, and transobturator slings. The surgeon makes small incisions behind the pubic bone or just by the sides of the vaginal opening as well as a small incision in the vagina. The surgeon uses specially designed needles to position a synthetic tape under the urethra. The surgeon pulls the ends of the tape through the incisions and adjusts them to provide the right amount of support to the urethra.8 For patients with pelvic prolapse, the surgeon may recommend an anti-incontinence procedure with a prolapse repair and possibly a hysterectomy.8 www.Nursing2013.com
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Nursing interventions for UI To plan individualized care, begin by obtaining the patient’s health history, including an evaluation of the patient’s urinary symptoms. To evaluate UI, start by asking these questions: • Do you ever involuntarily leak urine? • How long have you leaked urine? • When do you leak urine? • How much urine do you leak? • What do you usually do about it?15 Patients’ answers may provide enough initial information to formulate a nursing plan including patient education, exercises, and potential referral. The patient may also be asked to complete a voiding (bladder) diary for a few days. This can help to determine more precisely patterns of urinary frequency and volume, as well as precipitating factors. Patient education may include improving glycemic control, managing constipation, avoiding certain beverages (such as alcohol or caffeine), or taking diuretics at the best time to minimize interruptions in activities such as sleeping. If the patient has signs and symptoms such as frequency, dysuria, and urgency that suggest urinary tract infection, the nurse obtains specimens for urinalysis and culture and sensitivity, as indicated. When SUI is suspected or its signs and symptoms are the most distressing, the nurse initiates pelvic floor muscle education, more commonly known as Kegel exercises. (See Kegel exercise tips for patients.) Depending on the type of UI, nurses may collaborate with other healthcare team members to provide additional therapies.8 Other nursing activities to promote urinary continence include the following: • maintaining adequate patient hydration; caution the patient not to try to control incontinence by dehydrating herself or himself • assisting with weight-loss plans • avoiding use of indwelling urinary catheters unless clearly indicated and www.Nursing2013.com
Kegel exercise tips for patients What are Kegel exercises? To do Kegel exercises, just squeeze your pelvic floor muscles. The part of your body that includes your hip bones is the pelvic area. At the bottom of the pelvis, several layers of muscle stretch between your legs. The muscles attach to the front, back, and sides of the pelvic bone. Kegel exercises are designed to make your pelvic floor muscles stronger. These are the muscles that hold up your bladder and help keep it from leaking. Building up your pelvic muscles with Kegel exercises can help with your bladder control. How do you exercise your pelvic muscles? Find the right muscles. Try one of the following ways to find the right muscles to squeeze.
• Imagine that you’re trying to stop passing gas. Squeeze the muscles you would use. If you sense a “pulling” feeling, you’re squeezing the right muscles.
• Imagine that you’re sitting on a marble and want to pick up the marble with your vagina. Imagine “sucking” the marble into your vagina.
• Lie down and put your finger inside your vagina. Squeeze as if you were trying to stop urine from coming out. If you feel tightness on your finger, you’re squeezing the right pelvic muscles. Let your doctor, nurse, or therapist help you. Many people have trouble finding the right muscles. Your doctor, nurse, or therapist can check to make sure you’re doing the exercises correctly. You can also exercise by using special weights or biofeedback. Ask your healthcare team about these exercise aids. Don’t squeeze other muscles at the same time. Be careful not to tighten your stomach, legs, or other muscles. Squeezing the wrong muscles can put more pressure on your bladder control muscles. Just squeeze the pelvic muscle. Don’t hold your breath. Repeat, but don’t overdo it. At first, find a quiet spot to practice—your bathroom or bedroom—so you can concentrate. Lie on the floor. Pull in the pelvic muscles and hold for a count of 3. Then relax for a count of 3. Work up to 10 to 15 repeats each time you exercise. Use an exercise log to keep track of your sessions. Do your pelvic exercises at least three times a day. Every day, use three positions: lying down, sitting, and standing. You can exercise while lying on the floor, sitting at a desk, or standing in the kitchen. Using all three positions makes the muscles strongest. Be patient. Don’t give up. It’s just 5 minutes, three times a day. You may not feel your bladder control improve until after 3 to 6 weeks. Still, most women do notice an improvement after a few weeks. Source: http://kidney.niddk.nih.gov/kudiseases/pubs/bcw_ez/insertC.aspx.
removing them as soon as no longer needed • modifying the environment to facilitate urinary continence; for instance, by using clothing with snaps or hook-and-loop fasteners for easier removal, moving the patient closer to toilet facilities, and providing ambulatory devices such as canes or walkers • appropriately using absorbent products and undergarments.
Many of these strategies require the nurse to educate others on the healthcare team. (See Finding more resources.) Pivotal role Nurses have much to contribute to the management of UI as clinicians, educators, and collaborators. Nurses in all settings can promote urinary continence by providing continued education and excellent November l Nursing2013 l 59
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Conference. Prevention of Fecal and Urinary Incontinence in Adults. Final Panel Statement. Bethesda, MD. December 10-12, 2007. http:// consensus.nih.gov/2007/incontinencestatement. htm#q1.
Finding more resources • National Association for Continence http://www.nafc.org
• The Simon Foundation for Continence http://www.simonfoundation.org
• National Institute of Diabetes and
4. Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. 7th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams and Wilkins; 2013. 5. Porth CM. Essentials of Pathophysiology. 3rd ed. Philadelphia, PA: Wolters Kluwer Health/ Lippincott Williams and Wilkins; 2011.
Digestive and Kidney Diseases http://www.niddk.nih.gov
6. Vasavada SP, Carmel ME, Rackley R. Urinary incontinence. Practice essentials. 2013. http:// emedicine.medscape.com/article/452289-overview.
• The American Congress of Obstetricians and Gynecologists http://www.acog.org
• Urology Care Foundation of the American Urological Association http://www.urologyhealth.org
care to those who have or are at risk for UI. ■ REFERENCES 1. DuBeau CE. Epidemiology, risk factors, and pathogenesis of urinary incontinence. UpToDate. 2013. http://www.uptodate.com. 2. Clemens JQ. Urinary incontinence in men. UpToDate. 2013. http://www.uptodate.com. 3. NIH Consensus Development Program. Office of Disease Prevention. NIH State-of-the-Science
13. Rackley R, Vasavada SP, Firoozi F, Ingber MS. Neurogenic bladder. 2011. http://emedicine. medscape.com/article/453539. 14. Rackley R, Vasavada SP, Ingber MS, Firoozi F. Urinary incontinence. Pelvic floor rehabilitation. 2013. http://emedicine.medscape.com/article/ 452289-treatment#aw2aab6b6b8. 15. Johnson V. Urinary incontinence: no one should suffer in silence. Am Nurse Today. 2008;3(11). http://www.americannursetoday.com/article.aspx? id=5258&fid=5244#.
7. Wilkinson K. A guide to assessing bladder function and urinary incontinence in older people. Nurs Times. 2009;105(40):20-22. http://www. nursingtimes.net/nursing-practice/clinical-zones/ older-people/a-guide-to-assessing-bladderfunction-and-urinary-incontinence-in-olderpeople/5007215.article.
16. Cameron AP, Heidelbaugh JJ, Jimbo M. Diagnosis and office-based treatment of urinary incontinence in adults. Part one: diagnosis and testing. Ther Adv Urol. 2013;5(4):181-187.
8. National Kidney and Urologic Diseases Information Clearinghouse (NKUIDC). Urinary incontinence in women. 2010. http://kidney.niddk. nih.gov/kudiseases/pubs/uiwomen/.
18. Gyhagen M, Bullarbo M, Nielsen TF, Milsom I. The prevalence of urinary incontinence 20 years after childbirth: a national cohort study in singleton primiparae after vaginal or caesarean delivery. BJOG. 2013;120(2):144-151.
9. Herbruck LF. Stress urinary incontinence: prevention, management, and provider education. Urol Nurs. 2008;28(3):200-206. 10. Gammack JK. Lower urinary tract symptoms. Clin Geriatr Med. 2010;26(2):249-260. 11. DuBeau CE. Approach to women with urinary incontinence. UpToDate. 2013. http://www. uptodate.com.
About
17. Subak LL, Richter HE, Hunskaar S. Obesity and urinary incontinence: epidemiology and clinical research update. J Urol. 2009;182(suppl 6):S2-S7.
Donna Scemons is an assistant professor and coordinator of the family nurse practitioner program in the College of Health and Human Services at California State University, Los Angeles. The author has disclosed that she’s a member of the speaker’s bureau of ConvaTec. DOI-10.1097/01.NURSE.0000435202.96023.d6
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52 l Nursing2013 l November
www.Nursing2013.com
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
in adults
BRITTAK /iSTOCK
URINARY INCONTINENCE (UI), the inability to voluntarily control urine loss in an adult with a history of continence, presents challenges for nurses, patients, caregivers, and the community. Although many may consider UI to be a normal part of aging or certain healthcare events, it’s normal only in infants. For adults, UI is a distressing and disabling disorder that many fail to disclose to healthcare professionals. This article reviews bladder function and discusses the four main types of UI in adults. Patient assessment and nursing interventions presented here are based on the type of UI: stress, urge, mixed, and overflow. Why is UI important? The National Institutes of Health posits that about 20 million women and 6 million men living in the community experience some type of UI in their lifetime.1 Although the epidemiology of UI hasn’t been studied in men as much as in women, generally speaking, the prevalence of UI in women is about twice that of men.2 Only 22% of men with signs and symptoms of UI seek care for UI compared with 45% of women.2 UI is much more common in people living in nursing homes than in the community, ranging from 43% to 77% in these residents. In the United States, 6% to 10% of nursing home admissions are due to UI. www.Nursing2013.com
Cognitive impairment is linked with a 1.5- to 3.5-fold increase in the risk of UI, especially when the person is more frail.1 The prevalence of UI (any leakage during the past year) in women ranges from about 25% to 50%, increasing with age. UI affects 30% to 60% of women during pregnancy. In a large representative U.S. survey of women who weren’t pregnant, moderate or severe UI (leaking more than just drops at least monthly) affected 7% of women ages 20 to 39, rising gradually to 32% for those age 80 or older. The frequency and volume (severity) of UI also increase with age.1 About half of affected women have stress incontinence, with mixed stress and urge incontinence next most common.1 As in women, UI rates increase with age in men. Among men living in the community, the prevalence of UI (defined as at least one episode in the past 12 months) increases from 4.8% in those ages 19 to 44 to 21.1% in those older than 65. In men older than 65, the prevalence of daily UI is 2% to 11%.2 Estimating types of UI in men is difficult because UI is affected by prostate disease treatment. Urge urinary incontinence is more common in men than in women, but mixed incontinence is relatively rare in men. Compared with men who don’t have UI, men with urge
incontinence are more likely to be depressed and to change their activities (for instance, work fewer hours, change jobs, or retire early).2 Direct and indirect costs of UI are estimated to be around $20 billion per year with a projected 35% increase over the next 10 years.3 These figures, based on imprecise estimates of prevalence, are higher than the known costs for patients with arthritis, pneumonia, influenza, or breast cancer.3 Considering the high incidence, prevalence, and estimated costs of UI, nurses providing all levels of care are professionally obligated to develop assessment and evaluation skills and individualized plans of care for patients who are at risk for or experiencing UI. To facilitate individual care planning through critical thinking, nurses need to review bladder function and risk factors for UI. (See Who’s at risk for UI?) Urinary bladder function The bladder’s functions are to store and then to empty urine. Controlling these functions involves the autonomic nervous system, which is involuntary, and the somatic nervous system, which is voluntary. The parasympathetic nervous system helps the bladder to empty by generating contractions of the smooth muscle of the bladder wall and relaxing the internal sphincter. The sympathetic November l Nursing2013 l 53
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
nervous system helps the bladder to fill by relaxing the smooth muscle of the bladder wall and contracting the internal sphincter. Voluntarily controlling urination and continence is the task of the striated muscles found in the external sphincter and pelvic floor. These muscles are innervated by the somatic nervous system.4,5 (See Picturing the male and female genitourinary systems.) Micturition, or the passage of urine, occurs when the detrusor muscle contracts to expel urine from the bladder. (See Close up of the bladder.) The detrusor muscle continues
into the bladder neck as circular muscles that are sometimes called the internal urethral sphincter. Extending obliquely behind the proximal urethra, they form the posterior urethra in men and the complete urethra in women. When the bladder relaxes, these muscles close, functioning as a sphincter or a shutoff valve. This sphincter is pulled open when the detrusor muscle contracts, changing the bladder’s shape. Measuring 2.5 to 3.5 cm (1 to 1.4 in) in women, the urethra is shorter than in men, where its length ranges from 16.5 to 18.5 cm (6.5 to 7.3 in).
Who’s at risk for UI?1,2,16-18 Category By gender
Those at highest risk Women are at higher risk than men, especially those who
• have given birth, especially those having their first child after age 30
• had vaginal deliveries, especially those causing pelvic prolapse*
• participate in high-impact exercises, which causes more leaking
• have had a hysterectomy • have had two or more urinary tract infections in the past 12 months. Men who’ve had prostate disease, especially with a history of prostate surgery or radiation therapy Age
• Women age 65 or older • Men age 60 or older • Risk increases with age
Neurologic conditions
• Stroke • Parkinson disease • Alzheimer disease • Spinal cord injury • Multiple sclerosis • Disc herniation • Normal pressure hydrocephalus
Other conditions
• Diabetes mellitus • Obesity • Chronic cough (chronic bronchitis, chronic obstructive pulmonary disease, asthma, smoking) • Smoke or smoked more than one pack per day • Heart failure • Diabetes insipidus • Certain cancers, such as urethral cancer
Potentially reversible factors
• Fecal impaction • Alcohol or caffeine intake • Medications, such as loop diuretics, oral contraceptives, and anticholinergics.
*No evidence shows that caesarian sections or episiotomies reduce UI.
54 l Nursing2013 l November
Women’s urethras are usually less resistant to urine outflow than men’s.5 The external sphincter is another circular muscle made up of striated muscle fibers around the urethra distal to the bladder’s base. This sphincter can stop micturition in progress and maintain continence even when bladder pressure is higher than normal. Finally, the pelvic floor’s skeletal muscle helps to support the bladder and maintain continence.6 Micturition is a two-phase cycle: the bladder-filling/storage phase and the bladder-emptying phase. Continent adults normally have voluntary control over when and where micturition occurs, including the ability to stop and start urine flow, and increase and decrease the flow rate. Normal bladder function requires coordination between the sensory and motor components of the involuntary autonomic and voluntary somatic nervous systems.5 Effects of aging The prevalence of UI increases with age.1 Although bladder capacity is about 300 to 500 mL, the urge for micturition occurs when the bladder contains about 150 to 300 mL of urine.6 Aging results in some common bladder changes, such as decreased bladder capacity and bladder elasticity, increased spontaneous detrusor contractions, and decreased ability to postpone micturition, causing more frequent voiding. Decreased detrusor muscle strength results in incomplete bladder emptying, and decreased urethral closing pressure may lead to dribbling or leaking.6,7 Main types of UI The four main types of UI are stress, urge, mixed, and overflow. Stress urinary incontinence (SUI) is described as involuntary urine leakage that occurs with activities such as laughing, coughing, sneezing, lifting, or climbing stairs. Although SUI is more common among postmenopausal women, younger women may experience it during aerobics or running www.Nursing2013.com
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
and during the week before menstruation. Premenstrual SUI may be a function of lower estrogen levels causing lower urethral muscle pressure.8 The underlying etiology of SUI is urethral hypermobility when the normal muscular supports at the urethrovesical junction fail. Underlying causes of urethral hypermobility in women include vaginal delivery, vaginal surgery, inadequate estrogen levels, pelvic radiation, trauma, certain neurogenic disorders, and advanced age.9 Intrinsic sphincter deficiency is a less common cause of SUI in women, but it should be considered when a patient experiences urinary leaking. Sphincter deficiency is more commonly seen as a result of aging, inadequate estrogen, irradiation, meningomyelocele, prior vaginal surgery, sacral cord lesions, or trauma.9 For men, SUI may result after prostatectomy when urethral sphincter nerves or muscles are damaged or from postoperative scar tissue formation. In these situations, men complain of urine leaking with coughing, sneezing, lifting, or other activities that increase intraabdominal pressure.9,10 Urge urinary incontinence is described as involuntary leakage of urine associated with a sudden strong feeling of bladder fullness and difficulty deferring micturition. The urine leakage ranges from a few drops to enough to completely soak undergarments.11 Although the exact etiology and pathology is poorly understood, the detrusor responds with involuntary overactivity during the filling phase.6 Mixed urinary incontinence is diagnosed when symptoms of SUI and urge incontinence occur together. Among middle-aged and older women, mixed urinary incontinence is the most common form of UI. Patients present with a history of urine leaking during activities that increase intraabdominal pressure and strong feelings of urgency at the same time.6 The goal of treatment is generally based on which symptoms the www.Nursing2013.com
Picturing the male and female genitourinary systems Female genitourinary system (cross-section)
Ureter (retro-peritoneal)
Ovary and fallopian tube
Uterus
Bladder
Ureteral orifice
Urethra External meatus Vagina
Rectum
Male genitourinary system (cross-section)
Ureter (retro-peritoneal) Vas deferens (retro-peritoneal)
Bladder
Trigone Prostatic urethra Prostate gland Penile urethra External meatus Rectum
patient perceives as being the worst. Conservative interventions are attempted first; if satisfactory symptom resolution isn’t achieved after a specific period, less conservative interventions such as surgery will be planned.
Overflow incontinence is continuous involuntary leakage or dribbling of urine that occurs with incomplete bladder emptying.11 Overflow incontinence affects patients with atonic or overdistended bladder, urethral obstruction, or detrusor November l Nursing2013 l 55
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sphincter dyssynergia (DSD).12 DSD occurs when the external urethral sphincter contracts at the same time the detrusor contracts, resulting in urinary outflow obstruction such as occurs in patients with neurogenic bladder.13 Signs and symptoms include suprapubic tenderness, frequent urge to void (especially at night), incomplete emptying, a urinary stream that starts and stops or is weak or slow, nocturia, dribbling, straining, and a sense of a full bladder.
tients with urge incontinence that doesn’t respond to behavioral treatments or drugs. The healthcare provider applies an external stimulator to determine if neuromodulation works for the patient; if signs and symptoms are reduced by 50%, a surgeon will implant the device. Although neuromodulation can be effective, it’s not for everyone. The therapy is expensive and requires surgery and possibly surgical revisions and replacement.8 Vaginal devices for stress incontiTypes of treatment nence. Weak pelvic muscles can Here are some of the latest methods cause stress incontinence. A pessary for treating UI. is a stiff ring that a healthcare profesBiofeedback uses measuring sional inserts into the vagina, where devices to help patients become it presses against the wall of the vaaware of their body’s functioning. By gina and the nearby urethra. The using electronic devices or diaries to pressure helps reposition the uretrack when the bladder and urethral thra, leading to less stress leakage. muscles contract, the patient can Teach a patient using a pessary to be gain control over these muscles. alert for possible vaginal and urinary Biofeedback can supplement pelvic tract infections and see her healthmuscle exercises and electrical stimcare provider regularly.8 ulation to relieve stress and urge Injections for stress incontinence. incontinence.8,14 Various bulking agents, such as colNeuromodulation, or stimulation lagen and carbon spheres, can be inof nerves to the bladder leaving the jected near the urinary sphincter. The spine, can be effective in some pabulking agent is injected into tissues around the bladder neck and urethra to Close up of the bladder5 make the tissues thickNote the flattening of epithelial cells when the bladder er and close the bladis full and the wall is stretched. der opening to reduce Epithelium when Epithelium when stress incontinence. bladder is empty bladder is full Before the injection is given, patients may need a skin test to determine whether they could have an allergic reaction to the Detrusor muscle material. Over time, the body may slowly Ureters eliminate certain bulking agents, so the patient will need repeat injections. Scientists are testing newer Trigone agents, including paInternal sphincter tients’ own muscle cells, to see if they’re External sphincter effective in treating stress incontinence.8
58 l Nursing2013 l November
Surgery for stress incontinence. In some women, the bladder can move out of its normal position, especially following childbirth. Surgeons have developed techniques for supporting the bladder so it returns to its normal position.8 Retropubic suspension uses sutures to support the bladder neck. In the Burch procedure, the most common operation, the surgeon makes an incision in the abdomen a few inches below the navel and then secures threads to strong ligaments within the pelvis to support the urethral sphincter. This procedure is often done at the time of an abdominal procedure such as a hysterectomy.8 Sling procedures are performed through a vaginal incision. Slings may consist of natural tissue or manmade material. The traditional sling procedure uses a strip of the patient’s fascia to cradle the bladder neck. The surgeon attaches both ends of the sling to the pubic bone or ties them in front of the abdomen just above the pubic bone.8 Midurethral slings are placed in newer procedures that can be performed on an outpatient basis. These procedures use synthetic mesh materials that the surgeon places midway along the urethra. The two general types of midurethral slings are retropubic slings, such as transvaginal tapes, and transobturator slings. The surgeon makes small incisions behind the pubic bone or just by the sides of the vaginal opening as well as a small incision in the vagina. The surgeon uses specially designed needles to position a synthetic tape under the urethra. The surgeon pulls the ends of the tape through the incisions and adjusts them to provide the right amount of support to the urethra.8 For patients with pelvic prolapse, the surgeon may recommend an anti-incontinence procedure with a prolapse repair and possibly a hysterectomy.8 www.Nursing2013.com
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Nursing interventions for UI To plan individualized care, begin by obtaining the patient’s health history, including an evaluation of the patient’s urinary symptoms. To evaluate UI, start by asking these questions: • Do you ever involuntarily leak urine? • How long have you leaked urine? • When do you leak urine? • How much urine do you leak? • What do you usually do about it?15 Patients’ answers may provide enough initial information to formulate a nursing plan including patient education, exercises, and potential referral. The patient may also be asked to complete a voiding (bladder) diary for a few days. This can help to determine more precisely patterns of urinary frequency and volume, as well as precipitating factors. Patient education may include improving glycemic control, managing constipation, avoiding certain beverages (such as alcohol or caffeine), or taking diuretics at the best time to minimize interruptions in activities such as sleeping. If the patient has signs and symptoms such as frequency, dysuria, and urgency that suggest urinary tract infection, the nurse obtains specimens for urinalysis and culture and sensitivity, as indicated. When SUI is suspected or its signs and symptoms are the most distressing, the nurse initiates pelvic floor muscle education, more commonly known as Kegel exercises. (See Kegel exercise tips for patients.) Depending on the type of UI, nurses may collaborate with other healthcare team members to provide additional therapies.8 Other nursing activities to promote urinary continence include the following: • maintaining adequate patient hydration; caution the patient not to try to control incontinence by dehydrating herself or himself • assisting with weight-loss plans • avoiding use of indwelling urinary catheters unless clearly indicated and www.Nursing2013.com
Kegel exercise tips for patients What are Kegel exercises? To do Kegel exercises, just squeeze your pelvic floor muscles. The part of your body that includes your hip bones is the pelvic area. At the bottom of the pelvis, several layers of muscle stretch between your legs. The muscles attach to the front, back, and sides of the pelvic bone. Kegel exercises are designed to make your pelvic floor muscles stronger. These are the muscles that hold up your bladder and help keep it from leaking. Building up your pelvic muscles with Kegel exercises can help with your bladder control. How do you exercise your pelvic muscles? Find the right muscles. Try one of the following ways to find the right muscles to squeeze.
• Imagine that you’re trying to stop passing gas. Squeeze the muscles you would use. If you sense a “pulling” feeling, you’re squeezing the right muscles.
• Imagine that you’re sitting on a marble and want to pick up the marble with your vagina. Imagine “sucking” the marble into your vagina.
• Lie down and put your finger inside your vagina. Squeeze as if you were trying to stop urine from coming out. If you feel tightness on your finger, you’re squeezing the right pelvic muscles. Let your doctor, nurse, or therapist help you. Many people have trouble finding the right muscles. Your doctor, nurse, or therapist can check to make sure you’re doing the exercises correctly. You can also exercise by using special weights or biofeedback. Ask your healthcare team about these exercise aids. Don’t squeeze other muscles at the same time. Be careful not to tighten your stomach, legs, or other muscles. Squeezing the wrong muscles can put more pressure on your bladder control muscles. Just squeeze the pelvic muscle. Don’t hold your breath. Repeat, but don’t overdo it. At first, find a quiet spot to practice—your bathroom or bedroom—so you can concentrate. Lie on the floor. Pull in the pelvic muscles and hold for a count of 3. Then relax for a count of 3. Work up to 10 to 15 repeats each time you exercise. Use an exercise log to keep track of your sessions. Do your pelvic exercises at least three times a day. Every day, use three positions: lying down, sitting, and standing. You can exercise while lying on the floor, sitting at a desk, or standing in the kitchen. Using all three positions makes the muscles strongest. Be patient. Don’t give up. It’s just 5 minutes, three times a day. You may not feel your bladder control improve until after 3 to 6 weeks. Still, most women do notice an improvement after a few weeks. Source: http://kidney.niddk.nih.gov/kudiseases/pubs/bcw_ez/insertC.aspx.
removing them as soon as no longer needed • modifying the environment to facilitate urinary continence; for instance, by using clothing with snaps or hook-and-loop fasteners for easier removal, moving the patient closer to toilet facilities, and providing ambulatory devices such as canes or walkers • appropriately using absorbent products and undergarments.
Many of these strategies require the nurse to educate others on the healthcare team. (See Finding more resources.) Pivotal role Nurses have much to contribute to the management of UI as clinicians, educators, and collaborators. Nurses in all settings can promote urinary continence by providing continued education and excellent November l Nursing2013 l 59
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Conference. Prevention of Fecal and Urinary Incontinence in Adults. Final Panel Statement. Bethesda, MD. December 10-12, 2007. http:// consensus.nih.gov/2007/incontinencestatement. htm#q1.
Finding more resources • National Association for Continence http://www.nafc.org
• The Simon Foundation for Continence http://www.simonfoundation.org
• National Institute of Diabetes and
4. Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. 7th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams and Wilkins; 2013. 5. Porth CM. Essentials of Pathophysiology. 3rd ed. Philadelphia, PA: Wolters Kluwer Health/ Lippincott Williams and Wilkins; 2011.
Digestive and Kidney Diseases http://www.niddk.nih.gov
6. Vasavada SP, Carmel ME, Rackley R. Urinary incontinence. Practice essentials. 2013. http:// emedicine.medscape.com/article/452289-overview.
• The American Congress of Obstetricians and Gynecologists http://www.acog.org
• Urology Care Foundation of the American Urological Association http://www.urologyhealth.org
care to those who have or are at risk for UI. ■ REFERENCES 1. DuBeau CE. Epidemiology, risk factors, and pathogenesis of urinary incontinence. UpToDate. 2013. http://www.uptodate.com. 2. Clemens JQ. Urinary incontinence in men. UpToDate. 2013. http://www.uptodate.com. 3. NIH Consensus Development Program. Office of Disease Prevention. NIH State-of-the-Science
13. Rackley R, Vasavada SP, Firoozi F, Ingber MS. Neurogenic bladder. 2011. http://emedicine. medscape.com/article/453539. 14. Rackley R, Vasavada SP, Ingber MS, Firoozi F. Urinary incontinence. Pelvic floor rehabilitation. 2013. http://emedicine.medscape.com/article/ 452289-treatment#aw2aab6b6b8. 15. Johnson V. Urinary incontinence: no one should suffer in silence. Am Nurse Today. 2008;3(11). http://www.americannursetoday.com/article.aspx? id=5258&fid=5244#.
7. Wilkinson K. A guide to assessing bladder function and urinary incontinence in older people. Nurs Times. 2009;105(40):20-22. http://www. nursingtimes.net/nursing-practice/clinical-zones/ older-people/a-guide-to-assessing-bladderfunction-and-urinary-incontinence-in-olderpeople/5007215.article.
16. Cameron AP, Heidelbaugh JJ, Jimbo M. Diagnosis and office-based treatment of urinary incontinence in adults. Part one: diagnosis and testing. Ther Adv Urol. 2013;5(4):181-187.
8. National Kidney and Urologic Diseases Information Clearinghouse (NKUIDC). Urinary incontinence in women. 2010. http://kidney.niddk. nih.gov/kudiseases/pubs/uiwomen/.
18. Gyhagen M, Bullarbo M, Nielsen TF, Milsom I. The prevalence of urinary incontinence 20 years after childbirth: a national cohort study in singleton primiparae after vaginal or caesarean delivery. BJOG. 2013;120(2):144-151.
9. Herbruck LF. Stress urinary incontinence: prevention, management, and provider education. Urol Nurs. 2008;28(3):200-206. 10. Gammack JK. Lower urinary tract symptoms. Clin Geriatr Med. 2010;26(2):249-260. 11. DuBeau CE. Approach to women with urinary incontinence. UpToDate. 2013. http://www. uptodate.com.
About
17. Subak LL, Richter HE, Hunskaar S. Obesity and urinary incontinence: epidemiology and clinical research update. J Urol. 2009;182(suppl 6):S2-S7.
Donna Scemons is an assistant professor and coordinator of the family nurse practitioner program in the College of Health and Human Services at California State University, Los Angeles. The author has disclosed that she’s a member of the speaker’s bureau of ConvaTec. DOI-10.1097/01.NURSE.0000435202.96023.d6
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