Urinary Incontinence - Assessment Bronwyn Peck Continence Nurse Advisor Grampians Regional...

Urinary Incontinence -

Assessment

Bronwyn PeckContinence Nurse Advisor

Grampians Regional Continence ServiceBallarat Health Services – Queen Elizabeth

Centre

Loss of control of the bladder or bowel that is involuntary and socially unacceptable

A symptom ….. not a disease

Grampians Regional Continence Service - Ballarat Health Services

Incontinence is……

Common….. Affects 4.2 million Australians aged over 15 living

in the community This is equivalent to 26% of the population This is predicted to rise to 5.6 million by 2030 Affects up to 37% of women Affects up to 13% of men Around 71% in residential care 70% of people affected do not seek advice


The extent of the problem

Enormous financial burden In 2010 in Australia total financial cost of

incontinence was estimated to be $42.9 billion This equates to $9,014 per person with incontinence Productivity losses of those with incontinence

estimated to be $34.1 billion in 2010 due to lower than average employment rates

Productivity losses of family and friends who care for people with incontinence on an unpaid basis $2.7 billion


The extent of the problem

Loss of independence Reduced social activity and isolation Decline in self care and physical health Feelings on fear, embarrassment, shame,

depression, anger and stress Loss of self esteem, dignity and confidence Increased burden

Social Costs

Something that affects all ages But those at particular risk include:

Children Pregnant women Women at menopause The elderly Those in hospital or other institutions Those with disabilities Sufferers of particular medical

conditions People who strain at stool


Who is prone to incontinence?

Altered urine production Hormonal changes Decrease in strength of pelvic floor muscles Prostatic hypertrophy Changes in the cortical micturition centre Neurological changes Mobility and dexterity Medical conditions Medications

Age related changes

A normal part of ageing Expected with childbearing There is nothing that can be done “I am the only one” Children will grow out of bedwetting It is not a serious problem


The myths about incontinence

Present a major problem in tackling this condition Attitudes of sufferers and their families Health professionals and carers The general public and the media

Grampians Regional Continence Service – Ballarat Health Services

Attitudes and incontinence

To be continent you need to be able to:

Be aware of an urge to void/pass urine Know what to do and where to go Be able to get there & manage clothing Store urine in bladder till right time Empty bladder on cue Manage wiping/drying/clothing


Continence is complex….

We need Intact central nervous system Intact peripheral nervous system Adequate mobility & dexterity Adequate cognition Bladder that is able to store and empty Intact & functioning urinary sphincters An environment that supports continence


Not just about the bladder

Dryness at all times Voiding 4-6 times per day & not more than once

at night Passing 250-400 mls of urine per void Ability to defer as long as required to get to toilet Passing a continuous stream of urine without

burning or pain Sense of incomplete emptying once finished


Normal Bladder Function

Assessment of incontinence is a necessary preliminary step in planning appropriate intervention and management of presenting problems.

As there are different types and causes of incontinence which impact on people differently, an individual approach is essential.

Continence Assessment

Need to identify the cause of the symptoms

The different types of incontinence require different treatments

Need to collect information so the correct type of management can be put into place


There are different types of urinary incontinence therefore:

When the person has been observed to have a continence problem

When a continence problem has changed

When current management is no longer effective and requires evaluation.

When do you do a continence assessment?

Person Family/carers Nursing team Local doctor Allied health workers, eg. OT, PT, dietician Community service personnel

Who should be involved?

Bladder symptoms: History of the condition Onset & duration Person’s perception of the problem

Bowel status Dietary & fluid intake Aids & appliances used and effectiveness


What basic information do we need to collect?

Social history Medical & surgical history

Obstetric/gynaecological Urological – including previous investigations

Medications Functional status

Cognitive, mobility, dexterity, ADL’s Environmental factors


For a complete assessment we need to collect…

Subjective data What the person tells you about the problem

Objective data What is observable about the problem

What is included in a continence assessment?

Objective data Medical history from medical records Medication list Urinalysis/MSU Bladder/bowel charts Functional assessment tools

MMT,CFT, Bartels X-rays/scans/ultrasounds Residual urine volumes Uroflowmetry/Urodynamics Physical Examination


Subjective data Person’s perception of the problem History of the condition

Onset, duration Medical and surgical history

Obstetric/gynaecological Urological Medications

Functional Status Cognitive, mobility, dexterity, ADL’s

Environmental factors


Medication review by a doctor may be warranted Examples of medications that could effect

continence: Opiates Antidepressants Antihypertensives (blood pressure medications) Diuretics Anticholinergics (possible urinary retention)

Effect of Medications

Design of the chart will depend on The purpose of charting The setting The client

They can be used for a number of purposes: Baseline Implementation of management Evaluation

Bladder diaries/charts

They are not the complete assessment, but form a part of the assessment

The data needs to be interpreted and used for the management

Recommendation is 3 full days of charting

Diaries/charts

Every chart needs to provide the following basic information:

Fluid intake – times and volumes of drinks Frequency/time of voiding Frequency/time of incontinent episodes Voided volumes/estimate of loss Other relevant information

Diaries/charts

At Base line 3 x 24 hour periods Person to self initiate If not able check regularly

To evaluate management Maintain current strategies Chart what is happening

Bladder diaries/charts

We need to be able to establish: Presence of patterns Frequency of voids Number of incontinent episodes Voided volumes & intervals

How can we change the current situation?

Using the data from the charts

Use the information collected to determine type of incontinence: Stress Incontinence Urge Incontinence Mixed Incontinence Overflow Incontinence Reflex Incontinence Functional Incontinence Transient Incontinence

Types of Urinary Incontinence

Urinary Incontinence -

Management

Andrea GreenContinence Nurse Consultant

Grampians Regional Continence ServiceBHS-QEC

Whilst we would like to, we can’t always achieve dryness for all

The aim of continence management should be improved quality of life and social continence

Social Continence when complete continence is not attainable,

appropriate aids and appliances can allow for socialization with absolute discretion

Whilst cure for all is ideal, our management needs to be achievable and realistic.

Goals of Continence Management


Involuntary loss of a small amount of urine, when coughing, sneezing or on sudden movements with increased abdominal pressure

Not enough pressure in urethra to stop leakWeakened sphincters & pelvic floor musclesExcessive intra-abdominal pressureNo detrusor contraction


Stress Incontinence

Causes Weakened pelvic floor muscles

Childbirth Persistent heavy lifting Obesity Straining at stool Chronic cough

Fall in oestrogen levels Sphincter damage post surgery


Stress Incontinence

Small amount of urine lost Difficulty stopping urine mid-stream Leakage with cough, sneezing, laughing,

lifting, standing up, position changes.

Stress Incontinence


Pelvic floor exercises Identify muscles to be exercised Do not over tire muscle Brochure, dvd Check technique Prescribed sets to monitor progress and

compliance Oestrogen cream/pessary ? Alter type of anti-hypertensive Brace pelvic floor to lift, before coughing etc


Management SUI

We want to close off the bladder neck so we stay “high and dry”

Technique… How often? 25% of women will bulge downward instead

of lifting up Lets do some now…

Pelvic floor muscle exercises


Involuntary loss of urine, associated with a strong desire to void

Complete bladder emptying – often a large volume

Usually as the result of an involuntary contraction of the detrusor muscle

Over active bladder


Urge Incontinence

Cystitis/Calculi/TumoursUrinary tract infectionConstipationCaffeine/food additivesMedications (anti-cholinergics)AnxietyNeurological causes

CVA M.S Parkinson’s Disease


Urge Incontinence

Inability to defer Urgency Frequency Decreased bladder capacity or large volumes Nocturia 2 or more Nocturnal enuresis


Urge Incontinence

Treat UTI Alleviate constipation Review type and amount of fluid intake Bladder retraining – deferment, don’t void “just

in case” Urge suppression strategies – high and dry Toileting times (sometimes) Oestrogen replacement Medications


Management of UUI

Inability to pass urine – so builds up and overflows Blockage of bladder outlet/ obstruction

Enlarged prostate, strictures, sphincters not relaxing on cue

Faecal impaction Bladder muscle not contracting sufficiently

e.g. Diabetes, some spinal injuries, MS Epidural anaesthetics


Overflow Incontinence

Persistent leakage or dribbling Post micturition dribbling Hesitancy Poor or interrupted stream Feeling of incomplete emptying Frequency, small voided volumes Nocturia X 2 UTI Distended abdomen (may be painless) Confirmed via bladder scanner

Overflow incontinence


Alleviate constipation Treat UTI Double void Toileting position Catheterise (long term/short term)

types of catheters/flip-flow valve /suprapubic cleaning and care instructions


Management of Overflow Incontinence

ISC - Intermittent Self Catheterisation dexterity, eye sight, sensation, mobility education of ISC/teaching techniques Product supply

Minipress Surgery


Management of Overflow Incontinence

Sensation to void is present but unable to reach the toilet in time (due to barriers rather than urgency)

There is complete bladder emptying Causes:

Cognitive impairment Impaired mobility Impaired dexterity Environmental reasons

Location or toilets Chair height Availability of toiletsGrampians Regional Continence Service - Ballarat

Health Services

Functional Incontinence

Physiotherapy or occupational therapy to improve mobility

Appropriate chair height Clothing alternation Remove obstacles blocking the path to the toilet Commode if toilet access is difficult Well lit and private toilet Toileting routines

Management of Functional Incontinence


An adequate fluid intake consists of About 1½ litres per day Minimal caffeinated fluids

Don’t go to the toilet “just in case”, except before bed

Ability to defer when not appropriate to void Avoid constipation Correct sitting positioning on toilet

Foot stool Leaning forward Relaxing abdominal musclesGrampians Regional Continence Service - Ballarat

Health Services

Good bladder habits

Fluid intake range 30 – 50ml per kg of body weight When encouraging adequate fluid, intake take into

consideration reduced sense of thirst with age & altered environment drinking habits likes & dislikes the person’s understanding ability to reach drinks.


Fluid Intake

a program must be individualised obtain a base-line bladder chart ensure good fluid intake chart periodically and use comparisons as bio-

feedback teach deferment techniques timed toileting

a regular pattern needs to be established prompted voiding

person needs help to initiate toiletingGrampians Regional Continence Service - Ballarat Health Services

Bladder Training

Presence of bacteria in the urine with the absence of clinical features 25-50% of Women in residential aged care 14-30% of Men at some time asymptomatic bacteriuria Urine odour alone Cloudy urine Why asymptomatic bacteriuria should not be treated

with antibiotics Affected residents suffer no increased mortality Following course of antibiotics there is a rapid re-

establishment of bacteria Increasing incidence of resistant bacteria with unnecessary

antibiotic useGrampians Regional Continence Service - Ballarat Health Services

Asymptomatic bacteriuria

Require 3 of the following features before treatment:

Dysuria Fever Frequency Urgency Flank pain Suprapubic pain Worsening functional/mental status Change in character of urine

Symptomatic UTI’s in anon-catheterised person


Ensure male/female setting is correct. Adjust the female/male setting for women who have had a hysterectomy

Ensure the scan head is pointing in the correct direction

3 cms above pubic bone - midlinePress button and release immediatelyNot to be used on pregnant women Inaccurate reading post birth


Portable Bladder Scan

Thank you

Questions?

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