inkontinensia urin4

september 22 :: vol 25 no 3 :: 2010 41NURSING STANDARD

URINARY INCONTINENCE is defined as theinvoluntary leaking of urine (Kelleher et al 1997). It remains a significant public health problem.Hunskaar et al (2004) found that in a Europeanstudy of women aged 18 years and over, 35%reported an involuntary loss of urine in the previous30 days. Incontinence also has a significant costimplication, with conservative estimates suggestingthat £424 million is spent annually on treatment inthe UK (The Continence Foundation 2000).

Incontinence can be classified in five categories(Box 1), but patients most commonly presentwith stress or urge incontinence. Twenty per centof respondents to a questionnaire reportedsymptoms of stress incontinence, 3.5% reportedurge incontinence and 21% experienced mixedsymptoms. Nine per cent (287 out of 3,273) ofpatients had moderate or severe symptoms of urinary incontinence. However, only 47%

of all patients reported their symptoms to a healthcare professional (Shaw et al 2006).

Incontinence can affect men and women and is often a greater problem in older age. In men,incontinence may be associated with prostateproblems such as benign prostatic enlargement;treatment for prostate enlargement withtransurethral resection of the prostate; prostatecancer; or other health problems, such as theeffects of a cerebrovascular accident. In women,factors contributing to incontinence include theeffects of pregnancy (stretching of the pelvic floorduring labour), menopause and obesity(Sampselle et al 2002). Other factors includecystitis, unstable bladder, neurologicalconditions such as multiple sclerosis, spinal cord injury and urinary tract infection.

The condition can result in embarrassment and social isolation. Those who do seek help willtypically visit primary care practitioners, but mayhave experienced symptoms for a long time beforedoing so. Many patients report a reluctance to seekhelp from healthcare professionals, believing thatlittle or nothing can be done (Audit Commission1999). This article outlines the types ofincontinence and the management strategies that may be used to assist patients to improvetheir symptoms.

Anatomy and physiology of the bladder

The urinary system comprises two kidneys, twoureters, a bladder and a urethra (Figure 1). Inwomen, the urethra is approximately 3-4cm long(Figure 2) and in men it is approximately 25cmlong (Figure 3), passing through the prostate(Steggall 2007).

The urinary bladder is a reservoir for urine that is embedded in a muscle called the detrusor. The detrusor muscle stretches as urine fills thebladder from the ureters. This results intransmission of afferent nerve impulses to thespinal cord and, in turn, to the brain. The brainfirst interprets the signal as a desire to void whenthere is approximately 150-200ml of urine in thebladder (Steggall 2007). The afferent impulses

Treatment of patients with urge or stress urinary incontinence

Hanzaree Z, Steggall MJ (2010) Treatment of patients with urge or stress urinary incontinence.Nursing Standard. 25, 3, 41-46. Date of acceptance: December 11 2009.

&art & science continence focus

SummaryThis article outlines the nursing assessment of urinary incontinence,and describes both conservative management of individuals withincontinence and common pharmacological treatment options. The article focuses on therapeutic options for patients with urge or stress incontinence.

AuthorsZahirah Hanzaree, continence nurse specialist, Barts and The LondonNHS Trust, London; and Martin J Steggall, associate dean, Pre-Registration Undergraduate Nursing and Midwifery, CityUniversity, London, and clinical nurse specialist in erectile dysfunction,Barts and The London NHS Trust, London. Email: [email protected]

KeywordsDrug therapy, patient assessment, urinary incontinence,urology nursingThese keywords are based on subject headings from the BritishNursing Index. All articles are subject to external double-blind peerreview and checked for plagiarism using automated software. Forauthor and research article guidelines visit the Nursing Standardhome page at www.nursing-standard.co.uk. For related articlesvisit our online archive and search using the keywords.

p41-46w3_ART&SCIENCE 20/09/2010 12:22 Page 41

42 september 22 :: vol 25 no 3 :: 2010 NURSING STANDARD

continue to be sent to the brain, leading to greater(and more urgent) desires to void, until thebladder is emptied.

In emptying the bladder, efferent impulses leavethe spinal cord and act on the detrusor and theinternal and external urinary sphincters. Thiscontracts the bladder and relaxes the sphincters,allowing urine to pass out of the urethra and thebody (Colbert et al 2009).

Nursing assessment

Incontinence is often a symptom of an underlyingcondition, and successful treatment depends onaccurate assessment and description of theproblem, rather than pragmatic provision of pads (Wagg et al 2008). Assessment of continenceshould have three main aims:

4Identification of reversible factors such as a change or reduction in fluids.

4Identification of patients who require referralfor specialist assessment and treatment, forexample to an occupational therapist.

4Determination of the appropriate management strategy.

The minimum information that should beprovided as part of an assessment includes:

4Length of time the patient has experiencedincontinence and how it has been managed.

4Type of incontinence, for example leakingurine on coughing or sneezing or having torush to the toilet to pass urine (Box 1).

4Volume and type of fluids ingested.

4Psychological state of the patient and the extentto which incontinence affects his or her lifestyle.

4Any medication that can contribute tocontinence problems, for example diuretics.

4Home environment, such as inability tophysically access the toilet because of decreased


4Stress – involuntary leakage of urine on exertion, sneezing or coughing.

4Urge –involuntary leakage accompanied, or immediately preceded, by astrong desire to void (urgency).

4Mixed – involuntary leakage associated with urgency and also withexertion, sneezing or coughing.

4Functional – involuntary leakage of urine resulting from physical orcognitive limitations in reaching or using the toilet.

4Overflow – leakage of small amounts of urine, occurring when thebladder is full. Potential causes include prostate enlargement; urethralstenosis; chronic constipation; neurological lesions; pelvic organ prolapse;hypoactive bladder as a result of neurological lesions; changes to thedetrusor muscle; diabetes neuropathy; post-spinal surgery; medicationsuch as chlorpromazine; and pain and anxiety.

(Adapted from the Scottish Intercollegiate Guidelines Network 2004)

BOX 1

Types of urinary incontinence

FIGURE 1

Urinary bladder

FIGURE 3

Bladderneck

Urethra Prostate

Smoothmuscle

Ureters

Urethralopenings

Pubic bone

Urinarybladder

Urethra

Penis

Prostate

Male urinary system

FIGURE 2

Urinarybladder

Pubic bone

Urethra

Vagina

Female urinary system



mobility, or distance to the toilet (for example,getting upstairs).

Assessment of urinary incontinence requiresexclusion of underlying disease, for examplediabetes mellitus or multiple sclerosis. Examinationmay include assessment of post-void residualvolume and urine microscopy, culture andsensitivity to exclude urinary tract infection. Any abnormality detected on urinalysis or urinemicroscopy, culture and sensitivity should beappropriately managed by a nurse practitioner or referred to the relevant medical team. Referralpathways can be developed locally with agreementof urologists or continence services, or the pathwaydeveloped by the Scottish Intercollegiate GuidelinesNetwork (SIGN) (2004) can be used to assist thenurse in recognising when referral is needed.

Post-void residual volume is most accuratelydetermined by catheterisation, although this is invasive, embarrassing and has the potential tointroduce infection to the bladder or to traumatisethe urethra (SIGN 2004). Alternative estimation of post-void residual volume can be achieved byultrasound of the bladder, which is relativelysimple provided that training has been providedand competency achieved as per local policy.

A voiding history may be needed and achievedthrough a voiding diary completed by the patient.Voiding diaries (also known as frequency volumecharts) are used to record the number and extentof urinary tract symptoms, for example volumevoided, frequency, nocturia, urgency andepisodes of incontinence (Table 1). Alternatively,bladder diaries can record holding times as wellas the amount, time and type of fluids consumed.

Pad weighing tests can be used in addition tovoiding charts. This is usually done by weighing a dry pad and then weighing it again after a settime of wearing. The increased weight is anindication of urine loss.

Urodynamic investigation may be required,particularly where detrusor overactivity issuspected. Urodynamic tests investigate thefunction of the lower urinary tract. Theycomprise uroflowmetry, cystometry and urethralpressure profile. Some patients may require a videocystometrogram, whereby the urinaryfilling and voiding phases can be observed onscreen; a contrast media is used in conjunctionwith X-rays to provide a visual record of anyanatomical deformity of the urinary system.

These investigations allow the nursepractitioner to identify how the bladder copeswith volumes of urine, and how the nervoussystem copes with the increase in stretch of thedetrusor muscle (Getliffe and Dolman 1997).

The decision to undertake urodynamic studiesrests with the medical team or nurse practitionerspecialising in this area, but there is lack of

agreement concerning which patients shouldundergo these investigations. If the nurse is notundertaking the procedure independently, his or her role may involve preparing the patient for investigation. This involves urethralcatheterisation and insertion of a rectal probe to measure abdominal pressure.

Conservative management of incontinence

The type of incontinence determines theintervention used to treat the patient. Stress andmixed incontinence are treated with pelvic floormuscle exercises, although these exercises are of unproven benefit in urge incontinence. Urgeincontinence may be treated with pelvic floormuscle exercises and bladder retraining. Stress incontinence Conservative managementof stress incontinence should include pelvic floormuscle exercises. The pelvic floor is a dynamicstructure consisting of muscles, fascia andligaments that span the pelvic outlet, providingsupport for the abdominal and pelvic viscera(Southon 2008). The pelvic floor muscles allowfor the passage of urine and faeces while at thesame time maintaining continence. Impairment in any of these functions can develop if the pelvicfloor muscles or facia are stretched.

Pregnancy and delivery of children is a time of major anatomical and physiological changes to the urinary tract. These may result in analteration in urinary tract function, mostcommonly manifested by the development ofurinary symptoms. Vaginal delivery can result in anatomical, neural and structural damage to the pelvic floor, and such changes may lead topermanent urinary tract dysfunction (Chalihaand Stanton 2002).

The nursing assessment might indicate that thecause of incontinence is related to environmentalor social factors, for example not being able to geton the toilet on time because of mobility issues orbeing unable to undo a zip or button because ofarthritic hands. In these cases, a referral tooccupational therapy may be more appropriatethan pelvic floor muscle exercises.

Pelvic floor muscle exercises were first describedas a treatment for urinary incontinence by Kegel in1948. The main aim is to strengthen the perivaginal

Time Intake Urine passed Leakage Notes

09.40 Coffee 150ml

10.35 300ml

11.00 ++ Cough

(Adapted from Scottish Intercollegiate Guidelines Network 2004)

TABLE 1

Example of a voiding chart



and perianal musculature to increase control ofurine leakage (Joanna Briggs Institute 2006). Oneadvantage of this approach is that many womencan be cured or have their symptoms improved.

Pelvic floor muscle or Kegel exercises can resultin an increase in the strength and tone of the pelvicfloor and enhancement of cortical awareness ofmuscle groups controlling urinary outflow. Theymay lead to enlargement of existing muscle fibres(Vella and Cardozo 2005).

There is strong evidence to support pelvic floormuscle training, with expected cure rates of up to 73% and improvement in symptoms in up to 97% of patients (Neumann et al 2006).However, it requires more than just handing out aleaflet on pelvic floor muscle exercises for successto be achieved. Patients will put as much effortinto performing exercises as healthcareprofessionals put into explaining them, andpatients need encouragement as well as regularassessment to achieve positive results.

Box 2 describes how Kegel exercises should be performed.

Guidelines from the National Institute forHealth and Clinical Excellence (NICE) (2006)indicate that a trial of supervised pelvic floormuscle training of at least three months’ durationshould be offered as first-line treatment to womenwith stress or mixed incontinence.Urge incontinence This form of incontinence issometimes called ‘overactive bladder’. Abrams et al (2002) defined overactive bladder as ‘urinaryurgency, with or without urge incontinence,usually with frequency and nocturia in theabsence of pathological or metabolic factors that would explain these symptoms’. Frequency has been described by Abrams et al (2002) asincreased daytime frequency of urination, andnocturia as waking at night once or more to void.Specific interventions include:

4Lifestyle interventions – these include modifyingthe amount of fluid consumed each day.

4Limitation of caffeine-containing drinks (tea or coffee) as caffeine can irritate the bladder,causing urinary frequency and urgency(Australian Government Department of Healthand Ageing 2007).

4Increase intake of fresh fruit and vegetables,particularly those with a high water content,for example melon or tomatoes, to preventconstipation.

4Encourage weight reduction – obesity is an independent risk factor for urinaryincontinence (Dallosso et al 2003). Increasingintra-abdominal pressure stretches thepudendal nerve, resulting in injury to the pelvicfloor and subsequent dysfunction (Cummingsand Rodning 2000).

4Stop drinking fluid two hours before bedtimeand ensure voiding before going to bed.

4Reduce alcohol consumption –alcohol inhibitsthe secretion of antidiuretic hormone, preventing urine concentration and increasingurinary output.

4Review medication that can affect bladderfunction, for example diuretics andantipsychotics.

4Medication may be efficacious in some patients,but drugs have side effects and frequently arenot continued indefinitely. They are thereforeregarded as an adjunct to conservative therapy.

Individuals with urge and stress incontinencehabitually use the toilet frequently to avoidaccidents. Frequent toileting can lead to areduction in bladder capacity; this, over aprolonged period of time, can result in the bladderreducing in size, which exacerbates rather thanrelieves the condition.


Kegel exercises are performed to strengthen the muscles of the pelvicfloor, to help increase support of the bladder and urethra. They can also beused postpartum to enable circulation to the perineum, which promotesfaster healing and increases pelvic floor muscle tone.

4Contract the muscles in the perineum or pelvic floor as if trying toprevent passage of intestinal gas.

4The muscles will draw upward and inward.

4Then, using the same group of muscles, try to stop an imaginary flow ofurine. It is important not to perform the exercises while actually passingurine because this may lead to problems with correct emptying.

4Avoid straining or bearing down motions while performing thecontractions. This can be avoided by exhaling gently with an openmouth as the muscles contract.

4The contractions should be intense, but should not involve the abdomen,thighs or buttocks.

4The contraction should be held for 5-10 seconds, but the person mayneed to work up to that duration.

4Rest for ten seconds between contractions.

4Build up sufficient strength to be able to perform ten of thesecontractions at any one sitting.

4Now try to perform a set of quick contractions – drawing in the pelvicfloor and holding it for one second before relaxing. Work up to doing ten of these contractions at any one time.

4A complete set of Kegel exercises, involving both slow and quickcontractions, should be performed three to four times per day.

(Adapted from Bernier and Sims 2009, Herbruck 2009)

BOX 2

Performance of Kegel exercises for pelvic floor muscle training



muscle activity and therefore ameliorate bladderfunction. The use of anticholinergic drugs, such asthose shown in Table 2, to inhibit overactivedetrusor contractions has been shown tosignificantly improve symptoms (Vella andCardozo 2005).

The traditional view is that, in overactive bladdersymptoms and/or detrusor overactivity, the drugacts by blocking the muscarinic receptors on thedetrusor muscle, which are stimulated byacetylcholine released from activated cholinergic(parasympathetic) nerves (Andersson et al2009).The mode of action is therefore to decrease theability of the bladder to contract, which occursduring the storage of urine phase, resulting indecreased urgency and increased bladder capacity(Anderson 2004). Treatment should be for sixweeks for accurate assessment of benefits and side effects, and should be reviewed after six months (SIGN 2004).

Anticholinergic drugs are still the most widelyused treatment for urgency and urge incontinence.However, current drugs lack selectivity for thebladder and effects on other organ systems mayresult in side effects, which limit their usefulness.For example, all anticholinergic drugs arecontraindicated in untreated narrow angleglaucoma. The side effects of anticholinergics are listed in Table 2. Overflow incontinence This condition may occuras a result of urethral obstruction. One potentialcause is prostate enlargement, which can occur inmost men from about 40 years of age. One of thetreatment options for this condition is the use of analpha blocker such as tamsulosin, which relaxesthe smooth muscle, producing an increase inurinary flow rate and an improvement inobstructive symptoms (Steggall 2007).

Treatment options

Recent developments in the management ofoveractive bladder have broadened the therapeutic

Name Mode of action Side effects/cautions

Oxybutynin Reduce detrusor Dry mouth, blurred hydrochloride, overactivity; depress vision, abdominal tolterodine tartrate, voluntary and involuntary discomfort, drowsiness, propiverine. detrusor contractions. nausea and dizziness.

Solifenacin succinate, M3-receptor selective Dry mouth, blurred darifenacin. antimuscarinics. vision, constipation.

Fesoterodine fumarate. Antimuscarinic. Dry mouth, constipation, dry eyes, dry throat, indigestion.

(Adapted from Abrams and Swift 2005, Andersson et al 2009)

Bladder retraining is a form of treatment forurge and stress incontinence. It is an educationaland behavioural process used to re-establishurinary control in adults (Karon 2005). Thespecific goals of bladder retraining include:

4Correcting faulty, habitual patterns of frequenturination.

4Improving the ability to control bladder urgency.

4Prolonging voiding intervals.

4Increasing bladder capacity.

Bladder retraining gradually re-establishesvoluntary control on bladder function by trainingthe bladder to hold progressively larger volumes of urine over longer periods. As the time intervalsgradually increase, the patient has the opportunityto learn how to inhibit contractions of the detrusormuscle. This results in increases in voided volumesand prolonged intervals between voids. Bladderretraining has three components:

4Patient education.

4Scheduled voiding with systematic delay in voiding.

4Positive reinforcement.

The retraining programme requires the patient to be able to inhibit the sensation of urgency, to postpone voiding and to void according to a timetable. Patients should be counselled thatbladder retraining takes time and perseverancebefore benefits are noticed.

NICE (2003) recommends a minimum of sixweeks’ bladder retraining as first-line treatmentfor all women with urge or mixed incontinence.The patient voids by the clock (every hour) duringwaking hours, but does not set an alarm to voidovernight. As the voiding intervals increase, thepatient uses distraction (diversion) and relaxationtechniques to help suppress any urgency. Otherstrategies to delay voiding include standing orsitting still on a hard chair and contracting thepelvic floor until the urgency diminishes.

Pharmacological therapy

Stress incontinence The main therapeutic optionfor stress incontinence is conservative treatment,although some patients may be prescribed alphablockers such as tamsulosin. Duloxetine, a serotonin-noradrenaline (norepinephrine) re-uptake inhibitor, has been used in this setting andbeen found to increase quality of life. However, it isunclear if the benefits are sustainable in the longerterm (Mariappan et al2005). Urge incontinence The success of bladderretraining can be augmented by using a group ofmedications (anticholinergics) that help to relax

TABLE 2

Common medications used to treat urge urinary incontinenceand mixed urinary incontinence



options for the treatment of incontinence. Pelvicfloor retraining programmes have been beneficialand improved quality of life for some patients, for example those with detrusor overactivity whoare unable to take anticholinergics because of sideeffects. The therapy is aimed at training the pelvicfloor and external urethral sphincter musclesthrough producing a series of electrically-inducedcontractions to improve strength and function.

For patients with idiopathic overactive bladdersymptoms who fail to respond to pelvic floorretraining programmes and medical therapy,botulinum toxin type A is the next option. Thisacts at the neuromuscular junction to break downthe intracellular proteins that aid in the release ofacetylcholine into the synaptic cleft (Dolly 2003).


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Dallosso HM, McGrother CW,Mathews RJ et al (2003) The association of diet and otherlifestyle factors with overactivebladder and stress incontinence: a longitudinal study in women. BJU International. 92, 1, 69-77.

Dolly O (2003) Synaptictransmission: inhibition ofneurotransmitter release bybotulinum toxins. Headache. 43, Suppl 1, S16-S24.

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Herbruck L (2009) Management ofwomen with reproductive disorders.In Black JM, Hawks JH (Eds)Medical-Surgical Nursing: ClinicalManagement for Positive Outcomes.Eighth edition. Elsevier Saunders, St Louis MO, 912-939.

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following childbirth. NursingStandard. 20, 33, 46-50.

Karon, S (2005) A team approach tobladder retraining: a pilot study.Urologic Nursing. 25, 4, 269-276.

Kelleher CJ, Cardozo LD, Khullar V,Salvatore S (1997) A newquestionnaire to assess the quality oflife of urinary incontinent women.British Journal of Obstetrics andGynaecology. 104, 12, 1374-1379.

Mariappan P, Alhasso AA, Grant A, N’Dow JMO (2005)Serotonin and noradrenaline reuptakeinhibitors (SNRI) for stress urinaryincontinence in adults. CochraneDatabase of Systematic Reviews.Issue 3.

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The result is that the muscle fibres served by thatsynapse fail to contract.

Conclusion

Urinary incontinence is a common and distressingproblem. Nurses should attempt to identify and promote continence at every opportunity.Lifestyle modification in terms of drinking habits can help, but the underlying cause ofincontinence needs to be identified accurately,assessed and treated. Nurses are able toencourage discussions designed to identify whencontinence problems occur and act as a resourceboth for intervention and for signposting forreferral of individuals with severe problems.Treatment options include behavioural and/orpharmacological intervention. The aim of anyintervention is to assist in curing or at leastcontrolling the symptoms NS

References


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