WHY: The symptom of urinary incontinence (UI) is the report of involuntary loss of urine sufficient to be a bother while the sign of UI is observed urinary leakage. Depending on the setting, up to two-thirds of older adults experience UI. Yet, UI should not be considered a normal consequence of aging. Despite available treatment options, UI is not adequately assessed and managed in the older adult population. UI is associated with falls, obesity, skin impairments, urinary tract infections, limited functional status, depression, impaired cognition, poor self-rated health, social isolation, and increased caregiver burden. Proper assessment identifies the type of UI: transient (acute) or established (chronic). Try This:® UI Part I focuses on assessing for contributing causes of transient UI, which is significantly under addressed both in clinical practice and in the health care literature. Try This:® UI Part IIfocuses on established UI. Transient UI is generally defined as a new-onset UI that, if left untreated, may lead established UI.

BEST TOOLS: Whether transient or established UI is suspected, a bladder diary is recommended for collecting information during both assessment and evaluation. Bladder diaries should collect the following data: UI episodes, associated activities during UI episodes, void times and volumes, fluid intake, absorbent product usage, and bowel movement episodes (Abrams et al., 2002; Haylen et al., 2010). Research (Honjo et al., 2009) suggests including urinary perception and feeling of bladder fullness. The mnemonic DIAPPERS (or TOILETED, an alternative mnemonic) provides a framework for focusing the assessment of possible causes of transient UI.

TARGET POPULATION: UI screening is appropriate at any age, but especially for older adults due to increased prevalence. Specific to transient UI, the at-risk patient population includes those with immobility, impaired cognition, depression, certain medication usage (e.g. diuretics and anticholinergics), stool impaction, environmental barriers, diabetes, infection, and estrogen depletion (Fantl et al., 1996; Milson et al., 2013; Resnick & Yalla, 1985).

VALIDITY AND RELIABILITY: The bladder diary has not been validated (Bright et al., 2011), but is still considered an important tool to collect historical data essential to the diagnosis and management of UI. A 7-day bladder diary is a reliable tool (Jeyaseelan et al., 2000; Locher et al., 2001), but is challenging to obtain in clinical settings due to its length; a three-day or two-day diary is more practical (Bright et al., 2011; Tincello et al., 2007). The DIAPPERS or TOILETED mnemonics can be helpful since a valid and reliable tool for distinguishing among possible causes of transient UI is not available (Resnick & Yalla, 1985; Staskin & Kelleher, 2013).

STRENGTHS AND LIMITATIONS: Bladder diaries, or records, continue to be the standard tool for assessing patterns of UI episodes. While the bladder diary requires validation testing in varied populations, its brevity and ability to be self-administrated are strengths for use in clinical settings. Practitioners may find either mnemonic, DIAPPERS or TOILETED, a useful memory aide to recall the most common causes of transient UI. 

FOLLOW-UP: Transient UI requires aggressive assessment and treatment of reversible causes. If left untreated, transient UI may transition to established UI. It is essential for nurses to regularly assess for transient UI and treat reversible causes across all health care settings.

MORE ON THE TOPIC:

Abrams, P., Cardozo, L., Fall, M., Griffiths, D., Rosier, P., Ulmsten, U., et al. (2002). The standardisation of terminology of lower urinary tract function: Report from the standardization sub-committee of the International Continence Society. Urology, 61, 37-49.

Bright, E., Drake, M., & Abrams, P. (2011). Urinary diaries: Evidence for the development and validation of diary content, format, and duration. Neurourology and Urodynamics, 30(3), 348-352.

Doughty, D. B. (2006). Urinary & fecal incontinence: Current management concepts. Mosby: St. Louis.

Dowling-Castronovo, A. & Bradway, C. (2016). Urinary incontinence. In Boltz, M., Capezuti, E., Fulmer, T. & Zwicker, D. (Eds.). Evidence-Based Geriatric Nursing Protocols for Best Practice (5th ed.) (Chapter 21, pp. 343-362). New York: Springer Publishing Company.

Dowling-Castronovo, A. & Specht, J.K. (2009). How to try this: Assessment of transient urinary incontinence in older adults. AJN, 109(2), 62-71.

Fantl, A., Newman, D.K., Colling, J., et al. (1996). Urinary incontinence in adults: Acute and chronic management. Clinical Practice Guideline No. 2. AHCPR publication No. 96-0682. Rockville, MD: Agency for Health Care Policy and Research, U.S. Department of Health and Human Services. Includes: Management of Urinary Incontinence in Primary Care with sample bladder record available at: http://www.ncbi.nlm.nih.gov/books/NBK52177/#A10592.
Note: This is an archived guideline for historical purposes.

Haylen, B.T. (2010). An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction, Neurourology and Urodynamics, 29, 4–20.

Honjo, H., Kawauchi, A., Ukimura, O., Nakao, M., Kitakoji, H., & Miki, T. (2009). Analysis of bladder diary with urinary perception to assess overactive bladder symptoms in community-dwelling women. Neurourology and Urodynamics, 28(8), 982-985.

Jeyaseelan, S.M., Roe, B.H., & Oldham, J.A. (2000). The use of frequency/volume charts to assess urinary incontinence. Physical Therapy Reviews, 5(3), 141-146.

Locher, J.L., Goode, P.S., Rothe, D.L., Worrell, R.L., & Burgio, K.L. (2001). Reliability assessment of the bladder diary for urinary incontinence in older women. Journal of Gerontology Series A – Biological Sciences & Medical Sciences, 56(1), M32-35.

National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC) website: http://kidney.niddk.nih.gov/index.aspx.

Milson, I., Altman, D., Cartwright, M.C., Lapitan, M.C., Nelson, R., Sillen, U. & Tikkinen, K. (2013). Epidemiology of urinary incontinence (UI) and other lower urinary tract symptoms (LUTS), pelvic organ prolapse (POP) and anal incontinence (AI). In P. Abrams, L. Cardozo, S. Khoury, & A. Wein (Eds.) Incontinence, 5th International Consultation on Incontinence (5th ed.), 17-108. Available at: https://www.ics.org/Publications/ICI_5/INCONTINENCE.pdf

Resnick, N.M., & Yalla, S.V. (1985). Management of urinary incontinence in the elderly. NEJM, 313, 800-804.

Staskin, D., & Kelleher, C. (Chairs, Committee 5). (2013). Patient-reported outcome assessment. In P. Abrams, L. Cardozo, S. Khoury, & A. Wein (Eds.) Incontinence, 5th International Consultation on Incontinence (5th ed.), 361-368. Available at: https://www.ics.org/Publications/ICI_5/INCONTINENCE.pdf.

Tincello, D.G., Williams, K.S., Joshi, M., Assassa, R.P., & Abrams, K.R. (2007). Urinary diaries: A comparison of data collected for three days versus seven days. Obstetrics & Gynecology, 109(2), 277-280.