Bringing Urinary Incontinence out of the (water)

SPPICES: Urinary Incontinence

Organizational Goal • To organize continence services in an integrated fashion that focuses on the identification of patients, assessing their condition and implementing the most appropriate treatment plan. This model of good practice will allow staff to achieve more responsive and effective continence services and assist patients.

SPPICES Questions 1.

Do you have problem passing water/getting to the bathroom on time? 2. Did you wear incontinence products at home? 3. If there is a catheter, is it still needed? 4. Was your last bowel movement 3 days ago?

Did you know that... • 50% - 70% of persons with UI don’t seek help.

• UI is a very common problem with treatments that work. • Most cases of UI can be markedly improved.

Prevalence • 15% - 30% of seniors in the community

• 15.3% in acute care facilities • 50% in nursing homes

Impact of UI • Physical • Psychosocial • Financial

Definition • A common, disruptive, and potentially disabling condition in the aging population. • An involuntary loss of urine in sufficient amounts or frequency to constitute a social and/or health problem. (Kane, Ouslander, & Abrass, 1994)

Requirements for Continence  Effective lower urinary tract functioning  storage & emptying  Adequate mobility and dexterity to use the toilet, toilet substitute, and to manage clothing  Adequate cognitive function to recognize toileting needs and to find a toilet/substitute  Motivation to be continent  Absence of environmental and iatrogenic barriers such as inaccessible toilets/substitutes, unavailable family/caregivers and drug side effects

Established/Persistent UI: The Bladder Normal Aging Changes

Anatomy

Physiology

Types of UI 1.

Acute / Reversible

2. Established/Persistent Overflow Urge Functional Stress

Causes of Acute/Reversible UI D I A P P E R S

Delirium Infection Atrophic Vaginitis/ Urethritis Pharmaceuticals Psychological causes Excess fluid Restricted mobility Stool impaction (Resnick, 1992)

Established UI: Overflow Urine loss (dribbling) associated with an overdistended bladder due to an obstruction in the urethra.

Signs and Symptoms:

 Leakage of small amounts of urine  Palpable or percussable bladder, suprapubic tenderness  Hesitancy on voiding, interrupted urine flow or post void dribbling  Urine loss without urge  Sensation of incomplete voiding or bladder fullness  Frequency

Established UI: Urge Involuntary loss of urine (usually larger amounts) associated with a sudden, strong desire to void.

Signs and Symptoms:  Sudden “urgency” to void  Nocturia and / or Enuresis  Moderate to large amounts of urine loss  Loss of urine at the sound of water running or when waiting to access a public toilet

Established UI: Functional Urinary leakage associated with the inability to toilet because of impairments in cognition and/or physical functioning, psychological unwillingness or environmental barriers.

Signs and Symptoms:  Report of being unable to get to the bathroom on time  Total emptying / large amounts of urine leakage  No incontinence when access to a bathroom and assistance with toileting available

Established UI: Stress An involuntary loss of urine (usually small amounts) with increases in intraabdominal pressure (ie. Cough, laugh, sneeze, exercise).

Signs and Symptoms:  Small amounts of urine leakage/loss associated with activity, lifting, coughing, sneezing, and/or laughing  Urine leakage during the day while person is active

Interventions • • • • • • •

Environmental Alterations Lifestyle Management Scheduling Regimes Pelvic Muscle Rehabilitation Continence Products Catheterization Occlusive & Pelvic Organ Support Devices • Medication • Surgery

New onset urinary incontinence Risk factors identified: Delirium/confusion Clinical Assessme nt

Symptom s

Type of Incontinenc e

Intervention s

Evaluatio n

Infection, urinary symptoms Atrophic vaginitis/urethritis Pharmaceuticals Psychologic disorders Endocrine disorders Restricted mobility Stool impaction

Frequency Noctuira Enuresis Moderate to large amount of urine loss

URGE

Bladder training Kegel exercises Liners/briefs if needed Environmental modifications Consider medical referral as indicated Provide urinal/commode

Subjective/obje ctive report of improvement Decreased use of liners/briefs

Small amount urine loss Associated with activity, Coughing Sneezing

STRESS

Kegel exercise Bladder training Bladder diary to establish routine Liners/briefs if needed Consider medical referral as indicated

Monitor weekly Subjective report of  in incontinent episodes

Frequent urination Post void dribbling Retention Hesitancy Sensation of fullness/pressure in abdomen Urine loss without urge

OVERFLOW

Allow patient sufficient time to void Encourage double void PVR using bladder scanner Contact MD if appropriate for I/O or catheterization order Provide urinal or commode Medication review

PVR Monitor daily then weekly

Unable to get to toilet on time

FUNCTIONAL

Scheduled toileting Avoid restraints Ensure toilet accessible Provide commode etc at bedside Modify fluid intake pattern Modify environment eg remove obstacles Ensure adequate lighting OT/PT assessment

Monitor weekly Subjective/objective report of  in incontinence episodes

Case Study Mr. Yeung is a 90 year old man with a history of dementia, CHF, and osteoarthritis. He is on 40mg lasix BID, and Tylenol # 3 prn for his pain. During his hospitalization for exacerbation of his CHF, he has a new onset of urinary incontinence.

What type of UI is Mr. Yeung experiencing? What would be your plan of action for him?