Many people would rather suffer silently than discuss their urinary incontinence. The topic is just too embarrassing and unpleasant—and after all, incontinence is a normal part of aging, isn’t it?
As a nurse, you know that incontinence is never normal. And you should know that if you don’t raise the topic with patients at risk for incontinence, they probably won’t talk about it. Knowing what to ask depends on your understanding of how the bladder normally functions and what can go wrong. (See How the lower urinary tract works in PDF by clicking download now button.)
Types of urinary incontinence
Urinary incontinence is a leakage of urine, no matter how much or how often. The National Association for Continence estimates that 25 million Americans have either chronic or transient urinary incontinence—problems that can lead to depression, isolation, diminished self- esteem, and work-related difficulties.
Urinary incontinence and urine retention can result from one or more problems:
• failure of the bladder to store urine
• failure of the bladder to empty adequately
• a combination of failure to store and failure to empty
• sensory problems, such as pain during bladder filling or neurologic disorders that impair stimuli transmission to or from the bladder.
The problem may be acute or chronic. Acute incontinence is the sudden onset of urine leakage caused by physical deficits (arthritis, bladder infection, difficulty ambulating) or environmental factors (delay in answering call lights). When the physical deficit or environmental factor is corrected, the incontinence disappears. To recall the conditions that cause acute incontinence, use the acronym DIAPPERS:
- Delirium or confusion
- Atrophic vaginitis
- Pharmacologic therapy
- Psychological problems (depression)
- Restricted mobility
- Stool impaction.
Chronic incontinence results from a disease process. Types of chronic incontinence include:
- Stress urinary incontinence is leakage of small amounts of urine when intra-abdominal pressure exceeds intraurethral pressure, such as during sneezing, coughing, laughing, or rising from a seated position. Contributing factors include traumatic vaginal birth, low estrogen levels, and lax pelvic floor muscles.
- Overactive bladder is characterized by urinary frequency (voiding more than eight times a day) and urgency (a sudden, strong urge to void). This type of incontinence results from involuntary bladder contractions caused by damage to nerves of the bladder, the brain or spinal cord, or the muscles that maintain continence. Overactive bladder is often associated with urge incontinence.
- Urge incontinence is leakage of large amounts of urine after a sudden, strong urge to void. It’s caused by involuntary bladder contractions, resulting from damage to nerves of the bladder, the brain or spinal cord, or the muscles that maintain continence.
- Overflow urinary incontinence is caused by incomplete bladder emptying that results in a spillover of small amounts of urine. Rare in women, this type of incontinence results from an obstruction such as benign prostatic hyperplasia (BPH), diabetic nerve damage, or diseases causing muscle weakness.
- Mixed urinary incontinence is a combination of stress incontinence and urge incontinence.
- Urine retention of more than 50 mL of urine in the bladder after voiding contributes to overflow incontinence. Retention can be caused by ineffective contraction of the detrusor bladder muscle, obstruction, tumors in the bladder neck or urethra, or strictures or scar tissue in the urethra. Intrinsic sphincter deficiency may occur after a prostatectomy if the sphincter is damaged above the genitourinary diaphragm. (See Understanding chronic incontinence in PDF by clicking download now button.)
At risk for incontinence
Urinary incontinence has modifiable and nonmodifiable risk factors. Modifiable risk factors include obesity, drugs, pelvic floor laxity, multiple vaginal deliveries, smoking, alcohol use, and caffeine intake. Nonmodifiable risk factors include advancing age, prostate surgery, and pelvic radiation therapy. White women have higher rates of moderate to severe incontinence than African-American women. Other risk factors include environmental factors, such as inaccessible toilets, and physical deficits that impair a person’s ability to use the toilet independently. Conditions such as diabetes, multiple sclerosis, and Parkinson’s disease as well as poor overall health also put people at risk.
According to the Agency for Healthcare Research and Quality, you should screen these high-risk patients for urinary leakage
- elderly patients
- frail adults
- patients with a history of stroke, diabetes, obesity, or poor overall health
- patients who have multiple comorbidities
- pregnant women
- women after vaginal childbirth
- women with vaginal prolapse
- men after urologic surgery such as prostatectomy
- men who have undergone radiation for prostate cancer.
Asking your patient about incontinence
If a patient complains of leakage, evaluate him or her to exclude the leakage as a symptom of an underlying medical condition. If you suspect urinary incontinence and the leakage developed recently, ask about signs and symptoms of urinary tract infection, such as:
- burning on urination
- suprapubic pressure or discomfort
- blood-tinged urine
- back pain.
An elderly patient may have atypical signs and symptoms, such as a change in behavior or mental status or a decreased appetite, without complaints of dysuria.
If you suspect incomplete bladder emptying, the patient should also be tested for postvoid residual urine, using a bladder scan or a postvoid catheterization. More than 50 mL of residual urine indicates ineffective bladder emptying.
Take a thorough history, asking these questions:
- When did the leakage start?
- How often does it occur?
- Is bowel function regular or do you have a history of constipation?
- Does leakage occur during intercourse?
- Do you notice anything that triggers or increases the leakage: coughing, increased caffeine intake, or a new medication?
- Does anything improve your ability to avoid leakage?
- Also, ask about medical conditions and obstetric history, if applicable. Ask the patient if he or she is taking prescribed drugs, over-the-counter drugs, or herbal supplements. Determine the effect leakage is having on your patient by asking a question like, “How much does the leakage affect your life?”
To assess the need for intervention, have the patient keep a voiding diary. When keeping a diary, many patients are surprised by the frequency and amount of leakage and fluid intake. A diary may indicate factors contributing to leakage, such as caffeine intake, activities, and fluids consumed before going to bed.
Zeroing in on the problem
Ask these questions to determine your patient’s specific problem:
- Do you experience strong urges to empty your bladder? (urgency)
- In an 8-hour period, how often do you have the urge to empty your bladder? (urgency)
- Do you have difficulty reaching the restroom in time to prevent leakage? (urge incontinence, overactive bladder)
- How often do you have leakage before reaching the restroom? (frequency)
- When you have leakage, does it just dampen your undergarments or require a change of clothes? (urge incontinence, if change of clothes needed)
- Do you routinely wear a pad as protection from leakage? (stress incontinence, urge incontinence, overflow incontinence)
- How many times a night do you get up to empty your bladder? (nocturia, if more than two)
- Do you always wake up in time to prevent leakage? (nocturnal enuresis)
- Do you experience leakage when you laugh, cough, bend, or stand up from a seated position? (stress incontinence)
- Do you have leakage when exercising? (stress incontinence)
- Do you have a strong urge to empty your bladder before the leakage occurs? (urge incontinence)
- Is your urine stream as strong as it used to be? (BPH)
- Do you have frequent urges to empty your bladder? (frequency, urgency, overactive bladder)
- Do you have to wait for the stream to begin? (BPH)
- Do you feel that you completely empty your bladder? (overflow incontinence, BPH)
- Do you experience dribbling after you have emptied your bladder? (overflow incontinence, BPH)
Examining the patient
If the patient is elderly and frail, check his or her alertness and functional status. For elderly patients, vital signs include orthostatic vital signs because orthostatic symptoms may make patients restrict their mobility.
The examination should also include an assessment of neck movement, specifically lateral rotation and flexion, and a check for wasting of the interosseous muscles of the hands. These changes suggest cervical spondylosis or stenosis with a secondary interruption of the inhibitory tracts to the detrusor, causing detrusor overactivity.
Look for evidence of volume overload, such as rales or pedal edema. Abdominal assessment includes palpating for masses and tenderness. A round, soft, tense mass above the pubic bone indicates bladder distention. Examine the patient’s joint mobility and function because impaired mobility can contribute to functional incontinence.
Inspect a woman’s vaginal mucosa for atrophy (thinning, pallor, and loss of rugae), which may indicate an estrogen deficiency associated with stress incontinence. Assess pelvic support with a split-speculum exam, removing the top blade of the speculum and holding the bottom blade firmly against the posterior vaginal wall for support. Have the patient cough and note if the urethra remains firmly fixed or swings quickly forward, indicating urethral hypermobility. Also, look for anterior vaginal-wall bulging to or through the level of the hymenal ring, which indicates an anterior-wall support defect or a cystocele. To examine posterior wall support for a rectocele, turn the single blade of the speculum to support the anterior vaginal wall and have the patient cough again.
Check uncircumcised men for phimosis (tight, unretractable foreskin) and balanitis (inflammation of glans penis). After retraction, return the foreskin to its position to avoid causing phimosis. To rule out masses or fecal impaction in men and women, conduct a rectal examination. In men, also note prostate consistency and symmetry.
A neurologic examination should include assessing cognitive status and motor strength and tone. Also, check perineal sensation, anal-sphincter tone, anal wink (in response to a light scratch of the perineal skin lateral to the anus), and bulbocavernosus reflex (similar anal contraction in response to a light squeeze of the clitoris or glans penis).
Intervention for urinary incontinence depends on the type of dysfunction and the patient’s age, dexterity, and cooperation. Treatment options include drug and nondrug therapies.
For stress, urge, or mixed incontinence or overactive bladder, a prescriber will select a drug that promotes the bladder’s ability to store urine. If the problem is overflow incontinence, urine retention, or BPH, the selected drug will promote bladder emptying. And if a patient has stress urinary incontinence, a barrier to urine leakage, such as periurethral collagen injections, may be used. (See Drug therapy for urinary incontinence in PDF by clicking download now button.)
Drugs that more selectively target bladder receptors are less likely to cause adverse effects than less selective drugs. For example, oxybutynin (Ditropan, Oxytrol), an anticholinergic that promotes the bladder’s ability to store urine by decreasing detrusor contractility, also affects anticholinergic receptors in other parts of the body, such as the saliva glands and sweat glands. Many patients taking oxybutynin complain of dry mouth and are at risk for overheating during extended sun exposure. By contrast, tolterodine (Detrol) more selectively targets bladder receptors, so patients experience less dry mouth and overheating.
As with any drug therapy, you should know the adverse effects and the interactions with other prescription drugs, over-the-counter drugs, and herbal preparations. If your patient is elderly or has hepatic or renal impairment, some drugs may require a dosage reduction.
Therapy also includes behavioral interventions in which the patient actively retrains the bladder (habit training) or strengthens the pelvic floor muscles to gain bladder control (Kegel exercises). Other therapies include using devices, such as vaginal weights to strengthen the pelvic floor muscles in women and a penile clamp to prevent postvoid dribbling in men.
Surgery for female incontinence includes bladder suspension with sling procedures and use of vaginal tape. Men with urine retention and overflow incontinence from BPH may undergo transurethral resection of the prostate if using selective prostate alpha-1a adrenergic receptor blockers, such as tamsulosin (Flomax), or alpha-reductase inhibitors, such as dutasteride (Avodart), doesn’t work. Using an indwelling urinary catheter to manage urinary incontinence should be the last treatment option reserved for patients with chronic, continual leakage causing skin damage. (See Using nonpharmacologic therapies in PDF by clicking download now button.)
Quality of life
Identifying a patient who has urinary incontinence can lead to a significant improvement in his or her quality of life. Teach these patients and their family members about bladder function and available treatments for urinary incontinence.
Make sure they understand that incontinence is not a normal part of aging and that it can be successfully treated.
Anger JT, Bharucha AE, Bliss DZ, et al. Prevention of fecal and urinary incontinence in adults. NIH State-Of-The-Science Conference. December 10-12, 2007. http://consensus.nih.gov/2007/2007IncontinenceSOS030main.htm. Accessed September 10, 2008.
Kinchen KS, Lee J, Fireman B, et al. The prevalence, burden, and treatment of urinary incontinence among women in a managed care plan. J Womens Health. 2007;16(3):415-422.
National Kidney and Urologic Diseases Information Clearinghouse. Urinary incontinence in women. 2007. kidney.niddk.nih.gov/statistics/uda/Urinary_Incontinence_in_Women-Chapter05.pdf. Accessed September 10, 2008.
Shamliyan T, Wyman J, Bliss DZ, Kane RL, Wilt TJ. Prevention of fecal and urinary incontinence in adults. Evidence Report/Technology Assessment No. 161. AHRQ Publication No. 08-E003. Rockville, MD: Agency for Healthcare Research and Quality; December 2007. http://www.ahrq.gov/downloads/pub/evidence/pdf/fuiad/fuiad.pdf. Accessed September 10, 2008.
See November 2008 references.
Vicki Y. Johnson is an Assistant Professor at the University of Alabama School of Nursing, University of Alabama at Birmingham. The planners and author of this CNE activity have disclosed no relevant financial relationships with any commercial companies pertaining to this activity.