Urinary Incontinence

Population studies from multiple countries reported UI prevalence between 5% and 70%, with most reporting between 25% and 45%. Prevalence increases with age, with more than 40% for the 70-year-old and older population (Milsom & Gyhagen, 2018). Of those receiving home care services, 40% have UI; and more than one third of short-term nursing home residents and close to 75% of long-term NH residents have UI (Gorina et al., 2014). Medications, constipation/fecal impaction, low fluid intake, environmental barriers, diabetes mellitus, stroke immobility, impaired cognition, malnutrition, and depression are factors specific to identifying older adults at risk of UI (Fantl et al., 1996; Holroyd-Leduc & Straus, 2004; Kresevic, 1997; Meijer et al., 2003; Offermans et al., 2009; Shamliyan et al., 2007; Thomas et al., 2005). Complications of UI include falls, skin irritation leading to pressure ulcers, social isolation, and depression (Bogner et al., 2002; Brown et al., 2000; Fantl et al., 1996; Goksin & Asiret, 2018; Hamid et al., 2015; Meng et al., 2016; Morris & Wagg, 2007). Nurses play a key role in the assessment and management of UI.

BACKGROUND

A.  Definitions

  1. UI is defined as the complaint of involuntary urine loss (Abrams et al., 2003; Haylen et al., 2010) or involuntary loss of urine sufficient to be a problem (Fantl et al., 1996; National Association for Continence, 1998).
    • Transient UI is characterized by the sudden onset of potentially reversible symptoms that typically have a duration of less than 6 months (Specht, 2005).

B.  Types of established UI include the following:

  1. Stress UI is defined as an involuntary loss of urine associated with activities that increase intra-abdominal pressure; more common among women, but occurs in men after a prostatectomy (Abrams et al., 2003; Fantl et al., 1996; Hunter et al., 2004; Jayasekara, 2009).
  2. Urge UI is characterized by an involuntary urine loss associated with a strong desire to void (urgency; Abrams et al., 2003; Fantl et al., 1996). An individual with OAB may complain of urinary urgency, with or without UI (Abrams et al., 2003; Haylen et al., 2010).
  3. Mixed UI is defined as a combination of stress UI and urge UI (Fantl et al., 1996; Jayasekara, 2009).
  4. Overflow UI is an involuntary loss of urine associated with overdistention of the bladder and may be caused by an underactive detrusor muscle or outlet obstruction, leading to overdistention of the bladder and overflow of urine (Abrams et al., 2003; Doughty, 2000; Fantl et al., 1996; Jayasekara, 2009).
  5. Functional UI is caused by nongenitourinary factors, such as cognitive or physical impairments that result in an inability of the individual to void independently (Fantl et al., 1996; B. Hodgkinson et al., 2008); however, continence may be achieved with support of caregivers (Barrie, 2016).

C.  Epidemiology

  1. In different healthcare settings across the globe, prevalence rates range between 5% and 70%, with most reporting between 25% and 45% (Milsom et al., 2014). In the United States, more than 33 million individuals report some type of UI or bladder condition (https://www.nafc.org/urinary-incontinence).
  2. UI studies specific to the acute care setting demonstrate that UI is present in 10% to 42% of older adults (Dowd & Campbell, 1995; Fantl et al., 1996; Kresevic, 1997; Palmer et al., 1992; Schultz et al., 1997); and prevalence of UI ranges from 8% to 46% among community-dwelling adult populations (Du Moulin et al., 2008; Erekson et al., 2016; Kwong et al., 2010; Lee et al., 2009; Sims et al., 2011); 37% among those living in residential care facilities; 40% of those receiving home care services; and more than a third of short-term nursing home residents and close to 75% of long-term NH residents have UI (Gorina et al., 2014). Therefore, implementation of an evidence-based protocol to guide assessment and care planning is essential.

PARAMETERS OF ASSESSMENT

A.  Document the presence or absence of UI for all patients (DuBeau et al., 2010).

B.  Document the presence or absence of an indwelling urinary catheter (John et al., 2018).

C.  For patients with UI, the nurse collaborates with interprofessional team members to:

  1. Determine whether the UI is transient, established (stress/urge/mixed/overflow/functional), or both and document (DuBeau et al., 2010; Fantl et al., 1996; Jayasekara, 2009; Johnson, Bulechek, McCloskey-Dochterman, Maas, & Moorhead, 2001; Qaseem et al., 2014). The mnemonic TOILETED (see Box 25.1), the UDI-6, and the MUDI may be used to help guide nursing assessment (Dowling-Castronovo, 2018; Lemack & Zimmern, 1999; Robinson & Shea, 2002; Uebersax et al., 1995).
  2. Identify and document the possible etiologies of UI (DuBeau et al., 2010; Fantl et al., 1996).

NURSING CARE STRATEGIES

A.  General principles that apply to prevention and management of all forms of UI

  1. Identify and treat causes of transient UI (DuBeau et al., 2010).
  2. Upon admission to a healthcare facility, identify and continue successful prefacility management strategies for established UI.
  3. Develop an individualized plan of care using data obtained from the history and physical examination and in collaboration with other team members. Implement toileting programs as needed (Gibson et al., 2018; Gray, 2017; Ostaszkiewicz et al., 2004; Rathnayake, 2009c; Thomas et al., 2019).
  4. Avoid medications that may contribute to UI (American Geriatrics Society Beers Criteria® Update Expert Panel, 2019; Newman & Wein, 2009).
  5. Avoid indwelling urinary catheters whenever possible to avoid the risk of CAUTI (Bouza, San Juan, Muñoz, Voss, & Kluytmans, 2001; Dowd & Campbell, 1995; Gould et al., 2009; Zimakoff et al., 1996).
  6. Monitor fluid intake and maintain an appropriate hydration schedule.
  7. Limit dietary bladder irritants (Gray & Haas, 2000; Vaughan et al., 2011).
  8. Consider adding weight management as a long-term goal in discharge planning to achieve a healthy BMI (Qaseem et al., 2014; Subak et al., 2005; Suskind et al., 2017).
  9. Modify the environment to facilitate continence (Fantl et al., 1996; Jirovec, 2000; Palmer, 1996).
  10. Provide patients with usual undergarments in expectation of continence, if possible.
  11. Prevent skin breakdown by providing immediate cleansing after an incontinent episode and utilizing barrier ointments (Callaghan et al., 2018; Ersser et al., 2005; Fader et al., 2007, 2008; Getliffe et al., 2007; Gray, 2017).
  12. Pilot test absorbent products to best meet patient, staff, and institutional preferences (Dunn et al., 2002), bearing in mind adult briefs have been associated with UTIs (Zimakoff et al., 1996).
  13. Assign exercise deemed safe and appropriate by healthcare providers (Ouslander et al., 2005; Talley et al., 2017).
  14. Perform constipation management (Fantl et al., 1996; Hill, 2016; B. Hodgkinson et al., 2008; Hunter, 2016; McClurg et al., 2016; Mounsey et al., 2015; Qaseem et al., 2014; Schuster et al., 2015; Vaughan et al., 2011).

B.  Strategies for specific problems:

  1. Stress UI
    • Teach PFMEs (DuBeau et al., 2010; B. Hodgkinson et al., 2008; Qaseem et al., 2014).
    • Provide toileting assistance and bladder training as needed (DuBeau et al., 2010; Qaseem et al., 2014).
    • Consider referral to other team members if pharmacological or surgical therapies are warranted (Bonner & Boyle, 2017; Deeks et al., 2017; Wright et al., 2017).
  2. Urge UI and OAB
    • Implement bladder training (retraining; DuBeau et al., 2010; Qaseem et al., 2014; Teunissen et al., 2004).
    • If patient is cognitively intact and motivated, provide information on urge inhibition (Gray, 2005; Hill, 2016; Smith, 2000).
    • Teach PFMEs to be used in conjunction with bladder training, and instruct in urge inhibition strategies (Flynn, Cell, & Luisi, 1994; Rathnayake, 2009a; Teunissen et al., 2004).
    • Collaborate with prescribing team members if pharmacological therapy is warranted.
    • Initiate referrals for those patients who do not respond to the aforementioned strategies.
  3. Overflow UI
    • Allow sufficient time for voiding.
    • Discuss with interprofessional team the need for determining a PVR (Newman & Wein, 2009; Shinopulos, 2000; see Box 25.2).
    • Instruct patients in double voiding and Crede’s maneuver (Doughty, 2000).
    • If catheterization is necessary, sterile intermittent catheterization is preferred over indwelling urinary catheterization (Saint et al., 2006; Terpenning et al., 1989; Warren, 1997).
    • Initiate referrals to other team members for patients requiring pharmacological or surgical intervention.
  4. Functional UI
    • Provide individualized scheduled toileting, timed voiding, or prompted voiding (Eustice et al., 2000; Gibson et al., 2018; Jirovec, 2000; Lee et al., 2009; Ostaszkiewicz et al., 2004; Thomas et al., 2019).
    • Provide adequate fluid intake.
    • Refer for physical and occupational therapy as needed (Hill, 2016).
    • Modify environment to maximize independence with continence (Fantl et al., 1996; Jirovec, 2000; Jirovec et al., 1988; Palmer, 1996).

EVALUATION OF EXPECTED OUTCOMES

A.  Patients will:

  1. Have fewer or no episodes of UI or complications associated with UI.

B.  Nurses will:

  1. Document assessment of continence status. If UI is identified, document and determine type of UI.
  2. Use interprofessional expertise and interventions to assess and manage UI.
  3. Include UI in discharge planning needs and refer as needed.

C.  Institutions will:

  1. Set achievable goals for preventing, reducing, and resolving transient UI.
  2. Require assessment and documentation policies for continence status (Fung et al., 2007; Schnelle & Smith, 2001).
  3. Provide access to evidence-based guidelines for evaluation and management of UI.
  4. Instruct staff to receive administrative support and ongoing education regarding assessment and management of UI.

FOLLOW-UP MONITORING OF CONDITION

A.  Provide patient/CG discharge education and referral to specialists, as needed.

B.  Incorporate CQI criteria into existing program (Anger et al., 2016; Fung et al., 2007), and measure quality indicators using an if-then approach (Schnelle & Smith, 2001).

C.  Identify areas for improvement and enlist interprofessional collaboration in devising strategies for improvement (Bonner & Boyle, 2017; Deeks et al., 2017; Wright et al., 2017).

RELEVANT PRACTICE GUIDELINES

American College of Physicians releases new recommendations for treating urinary incontinence in women

https://www.acponline.org/acp-newsroom/american-college-of-physicians-releases-new-recommendations-for-treating-urinary-incontinence-in

2012 Update: Guidelines for Adult Urinary Incontinence Collaborative Consensus Document for the Canadian Urological Association

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3478335

ABBREVIATIONS

BMI             Body mass index

CAUTI        Catheter-associated urinary tract infection

CG               Caregiver

CQI             Continuous quality improvement

NH              Nursing home

OAB            Overactive bladder

PFME          Pelvic floor muscle exercises

PVR            Postvoid residual

UI                Urinary incontinence

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Updated: November 2020

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti PhD, RN, FAAN, E., Zwicker DrNP, APRN, BC, D., & Fulmer PhD, RN, FAAN, T. T. (2020). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed.). Springer Publishing. Retrieved November 4, 2020, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826188144.html#description

Chapter 25: Dowling-Castronovo, A., Long, J., & Bradway, C. (2021) Urinary Incontinence in the Older Adult.  In M. Boltz, E. Capezuti, D. Zwicker & T. Fulmer (eds.).  Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed. pp 439-466).   New York: Springer.

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Palmer, M. H., Baumgarten, M., Langenberg, P., & Carson, J. L. (2002). Risk factors for hospital-acquired incontinence in elderly female hip fracture patients. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 57(10), M672–M677. doi:10.1093/gerona/57.10.M672. Evidence Level IV.

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Rathnayake, T. (2009c). Urinary incontinence: Timed voiding. JBI Database of Evidence Summaries, Publication ES5330. Evidence Level I.

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Shinopulos, N. (2000). Bedside urodynamic studies: Simple testing for urinary incontinence. Nurse Practitioner, 25(6 Pt 1), 19–22, 25. doi:10.1097/00006205-200025060-00002. Evidence Level VI.

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