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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.

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

Authors
Zahirah Hanzaree, continence nurse specialist, Barts and The London NHS Trust, London; and Martin J Steggall, associate dean, Pre-Registration Undergraduate Nursing and Midwifery, City University, London, and clinical nurse specialist in erectile dysfunction, Barts and The London NHS Trust, London. Email: zahirah.hanzaree@bartsandthelondon.nhs.uk

Keywords
Drug therapy, patient assessment, urinary incontinence, urology nursing These keywords are based on subject headings from the British Nursing Index. All articles are subject to external double-blind peer review and checked for plagiarism using automated software. For author and research article guidelines visit the Nursing Standard home page at www.nursing-standard.co.uk. For related articles visit our online archive and search using the keywords.

URINARY INCONTINENCE is defined as the involuntary leaking of urine (Kelleher et al 1997). It remains a significant public health problem. Hunskaar et al (2004) found that in a European study of women aged 18 years and over, 35% reported an involuntary loss of urine in the previous 30 days. Incontinence also has a significant cost implication, with conservative estimates suggesting that 424 million is spent annually on treatment in the UK (The Continence Foundation 2000). Incontinence can be classified in five categories (Box 1), but patients most commonly present with stress or urge incontinence. Twenty per cent of respondents to a questionnaire reported symptoms of stress incontinence, 3.5% reported urge incontinence and 21% experienced mixed symptoms. Nine per cent (287 out of 3,273) of patients had moderate or severe symptoms of urinary incontinence. However, only 47% NURSING STANDARD

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 prostate problems such as benign prostatic enlargement; treatment for prostate enlargement with transurethral resection of the prostate; prostate cancer; or other health problems, such as the effects of a cerebrovascular accident. In women, factors contributing to incontinence include the effects of pregnancy (stretching of the pelvic floor during labour), menopause and obesity (Sampselle et al 2002). Other factors include cystitis, unstable bladder, neurological conditions 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 will typically visit primary care practitioners, but may have experienced symptoms for a long time before doing so. Many patients report a reluctance to seek help from healthcare professionals, believing that little or nothing can be done (Audit Commission 1999). This article outlines the types of incontinence and the management strategies that may be used to assist patients to improve their symptoms.

Anatomy and physiology of the bladder

The urinary system comprises two kidneys, two ureters, a bladder and a urethra (Figure 1). In women, the urethra is approximately 3-4cm long (Figure 2) and in men it is approximately 25cm long (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 the bladder from the ureters. This results in transmission of afferent nerve impulses to the spinal cord and, in turn, to the brain. The brain first interprets the signal as a desire to void when there is approximately 150-200ml of urine in the bladder (Steggall 2007). The afferent impulses september 22 :: vol 25 no 3 :: 2010 41

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continue to be sent to the brain, leading to greater (and more urgent) desires to void, until the bladder is emptied. In emptying the bladder, efferent impulses leave the spinal cord and act on the detrusor and the internal and external urinary sphincters. This contracts the bladder and relaxes the sphincters, allowing urine to pass out of the urethra and the body (Colbert et al 2009).

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4Psychological state of the patient and the extent to which incontinence affects his or her lifestyle. 4Any medication that can contribute to continence problems, for example diuretics. 4Home environment, such as inability to physically access the toilet because of decreased FIGURE 1 Urinary bladder
Ureters

Nursing assessment
Incontinence is often a symptom of an underlying condition, and successful treatment depends on accurate assessment and description of the problem, rather than pragmatic provision of pads (Wagg et al 2008). Assessment of continence should have three main aims: 4Identification of reversible factors such as a change or reduction in fluids. 4Identification of patients who require referral for specialist assessment and treatment, for example to an occupational therapist. 4Determination of the appropriate management strategy. The minimum information that should be provided as part of an assessment includes: 4Length of time the patient has experienced incontinence and how it has been managed. 4Type of incontinence, for example leaking urine on coughing or sneezing or having to rush to the toilet to pass urine (Box 1). 4Volume and type of fluids ingested. BOX 1 Types of urinary incontinence 4Stress involuntary leakage of urine on exertion, sneezing or coughing. 4Urge involuntary leakage accompanied, or immediately preceded, by a
strong desire to void (urgency). Urinary bladder Pubic bone Urethra Vagina Urethral openings

Bladder neck Urethra

Smooth muscle Prostate

FIGURE 2 Female urinary system

FIGURE 3 Male urinary system

4Mixed involuntary leakage associated with urgency and also with

exertion, sneezing or coughing. Pubic bone Urinary bladder Urethra Penis

4Functional involuntary leakage of urine resulting from physical or

cognitive limitations in reaching or using the toilet.

4Overflow leakage of small amounts of urine, occurring when the

bladder is full. Potential causes include prostate enlargement; urethral stenosis; chronic constipation; neurological lesions; pelvic organ prolapse; hypoactive bladder as a result of neurological lesions; changes to the detrusor muscle; diabetes neuropathy; post-spinal surgery; medication such as chlorpromazine; and pain and anxiety.
(Adapted from the Scottish Intercollegiate Guidelines Network 2004)

Prostate

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mobility, or distance to the toilet (for example, getting upstairs). Assessment of urinary incontinence requires exclusion of underlying disease, for example diabetes mellitus or multiple sclerosis. Examination may include assessment of post-void residual volume and urine microscopy, culture and sensitivity to exclude urinary tract infection. Any abnormality detected on urinalysis or urine microscopy, culture and sensitivity should be appropriately managed by a nurse practitioner or referred to the relevant medical team. Referral pathways can be developed locally with agreement of urologists or continence services, or the pathway developed by the Scottish Intercollegiate Guidelines Network (SIGN) (2004) can be used to assist the nurse in recognising when referral is needed. Post-void residual volume is most accurately determined by catheterisation, although this is invasive, embarrassing and has the potential to introduce infection to the bladder or to traumatise the urethra (SIGN 2004). Alternative estimation of post-void residual volume can be achieved by ultrasound of the bladder, which is relatively simple provided that training has been provided and competency achieved as per local policy. A voiding history may be needed and achieved through a voiding diary completed by the patient. Voiding diaries (also known as frequency volume charts) are used to record the number and extent of urinary tract symptoms, for example volume voided, frequency, nocturia, urgency and episodes of incontinence (Table 1). Alternatively, bladder diaries can record holding times as well as the amount, time and type of fluids consumed. Pad weighing tests can be used in addition to voiding charts. This is usually done by weighing a dry pad and then weighing it again after a set time of wearing. The increased weight is an indication of urine loss. Urodynamic investigation may be required, particularly where detrusor overactivity is suspected. Urodynamic tests investigate the function of the lower urinary tract. They comprise uroflowmetry, cystometry and urethral pressure profile. Some patients may require a videocystometrogram, whereby the urinary filling and voiding phases can be observed on screen; a contrast media is used in conjunction with X-rays to provide a visual record of any anatomical deformity of the urinary system. These investigations allow the nurse practitioner to identify how the bladder copes with volumes of urine, and how the nervous system copes with the increase in stretch of the detrusor muscle (Getliffe and Dolman 1997). The decision to undertake urodynamic studies rests with the medical team or nurse practitioner specialising in this area, but there is lack of NURSING STANDARD

TABLE 1 Example of a voiding chart

Time 09.40 10.35 11.00 Intake Coffee 150ml 300ml ++ Cough Urine passed Leakage Notes

(Adapted from Scottish Intercollegiate Guidelines Network 2004)

agreement concerning which patients should undergo these investigations. If the nurse is not undertaking the procedure independently, his or her role may involve preparing the patient for investigation. This involves urethral catheterisation and insertion of a rectal probe to measure abdominal pressure.

Conservative management of incontinence

The type of incontinence determines the intervention used to treat the patient. Stress and mixed incontinence are treated with pelvic floor muscle exercises, although these exercises are of unproven benefit in urge incontinence. Urge incontinence may be treated with pelvic floor muscle exercises and bladder retraining. Stress incontinence Conservative management of stress incontinence should include pelvic floor muscle exercises. The pelvic floor is a dynamic structure consisting of muscles, fascia and ligaments that span the pelvic outlet, providing support for the abdominal and pelvic viscera (Southon 2008). The pelvic floor muscles allow for the passage of urine and faeces while at the same time maintaining continence. Impairment in any of these functions can develop if the pelvic floor 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 an alteration in urinary tract function, most commonly manifested by the development of urinary symptoms. Vaginal delivery can result in anatomical, neural and structural damage to the pelvic floor, and such changes may lead to permanent urinary tract dysfunction (Chaliha and Stanton 2002). The nursing assessment might indicate that the cause of incontinence is related to environmental or social factors, for example not being able to get on the toilet on time because of mobility issues or being unable to undo a zip or button because of arthritic hands. In these cases, a referral to occupational therapy may be more appropriate than pelvic floor muscle exercises. Pelvic floor muscle exercises were first described as a treatment for urinary incontinence by Kegel in 1948. The main aim is to strengthen the perivaginal september 22 :: vol 25 no 3 :: 2010 43

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and perianal musculature to increase control of urine leakage (Joanna Briggs Institute 2006). One advantage of this approach is that many women can be cured or have their symptoms improved. Pelvic floor muscle or Kegel exercises can result in an increase in the strength and tone of the pelvic floor and enhancement of cortical awareness of muscle groups controlling urinary outflow. They may lead to enlargement of existing muscle fibres (Vella and Cardozo 2005). There is strong evidence to support pelvic floor muscle 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 a leaflet on pelvic floor muscle exercises for success to be achieved. Patients will put as much effort into performing exercises as healthcare professionals put into explaining them, and patients need encouragement as well as regular assessment to achieve positive results. Box 2 describes how Kegel exercises should be performed. BOX 2 Performance of Kegel exercises for pelvic floor muscle training
Kegel exercises are performed to strengthen the muscles of the pelvic floor, to help increase support of the bladder and urethra. They can also be used postpartum to enable circulation to the perineum, which promotes faster healing and increases pelvic floor muscle tone.

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Guidelines from the National Institute for Health and Clinical Excellence (NICE) (2006) indicate that a trial of supervised pelvic floor muscle training of at least three months duration should be offered as first-line treatment to women with stress or mixed incontinence. Urge incontinence This form of incontinence is sometimes called overactive bladder. Abrams et al (2002) defined overactive bladder as urinary urgency, with or without urge incontinence, usually with frequency and nocturia in the absence of pathological or metabolic factors that would explain these symptoms. Frequency has been described by Abrams et al (2002) as increased daytime frequency of urination, and nocturia as waking at night once or more to void. Specific interventions include: 4Lifestyle interventions these include modifying the 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 Health and Ageing 2007). 4Increase intake of fresh fruit and vegetables, particularly those with a high water content, for example melon or tomatoes, to prevent constipation. 4Encourage weight reduction obesity is an independent risk factor for urinary incontinence (Dallosso et al 2003). Increasing intra-abdominal pressure stretches the pudendal nerve, resulting in injury to the pelvic floor and subsequent dysfunction (Cummings and Rodning 2000). 4Stop drinking fluid two hours before bedtime and ensure voiding before going to bed. 4Reduce alcohol consumption alcohol inhibits the secretion of antidiuretic hormone, preventing urine concentration and increasing urinary output. 4Review medication that can affect bladder function, for example diuretics and antipsychotics. 4Medication may be efficacious in some patients, but drugs have side effects and frequently are not continued indefinitely. They are therefore regarded as an adjunct to conservative therapy. Individuals with urge and stress incontinence habitually use the toilet frequently to avoid accidents. Frequent toileting can lead to a reduction in bladder capacity; this, over a prolonged period of time, can result in the bladder reducing in size, which exacerbates rather than relieves the condition. NURSING STANDARD

4Contract the muscles in the perineum or pelvic floor as if trying to

prevent passage of intestinal gas.

4The muscles will draw upward and inward. 4Then, using the same group of muscles, try to stop an imaginary flow of
urine. It is important not to perform the exercises while actually passing urine because this may lead to problems with correct emptying.

4Avoid straining or bearing down motions while performing the

contractions. This can be avoided by exhaling gently with an open mouth 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 may
need to work up to that duration.

4Rest for ten seconds between contractions. 4Build up sufficient strength to be able to perform ten of these
contractions at any one sitting.

4Now try to perform a set of quick contractions drawing in the pelvic

floor 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 quick

contractions, should be performed three to four times per day.
(Adapted from Bernier and Sims 2009, Herbruck 2009)

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Bladder retraining is a form of treatment for urge and stress incontinence. It is an educational and behavioural process used to re-establish urinary control in adults (Karon 2005). The specific goals of bladder retraining include: 4Correcting faulty, habitual patterns of frequent urination. 4Improving the ability to control bladder urgency. 4Prolonging voiding intervals. 4Increasing bladder capacity. Bladder retraining gradually re-establishes voluntary control on bladder function by training the bladder to hold progressively larger volumes of urine over longer periods. As the time intervals gradually increase, the patient has the opportunity to learn how to inhibit contractions of the detrusor muscle. This results in increases in voided volumes and prolonged intervals between voids. Bladder retraining 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 that bladder retraining takes time and perseverance before benefits are noticed. NICE (2003) recommends a minimum of six weeks bladder retraining as first-line treatment for all women with urge or mixed incontinence. The patient voids by the clock (every hour) during waking hours, but does not set an alarm to void overnight. As the voiding intervals increase, the patient uses distraction (diversion) and relaxation techniques to help suppress any urgency. Other strategies to delay voiding include standing or sitting still on a hard chair and contracting the pelvic floor until the urgency diminishes.

muscle activity and therefore ameliorate bladder function. The use of anticholinergic drugs, such as those shown in Table 2, to inhibit overactive detrusor contractions has been shown to significantly improve symptoms (Vella and Cardozo 2005). The traditional view is that, in overactive bladder symptoms and/or detrusor overactivity, the drug acts by blocking the muscarinic receptors on the detrusor muscle, which are stimulated by acetylcholine released from activated cholinergic (parasympathetic) nerves (Andersson et al 2009). The mode of action is therefore to decrease the ability of the bladder to contract, which occurs during the storage of urine phase, resulting in decreased urgency and increased bladder capacity (Anderson 2004). Treatment should be for six weeks for accurate assessment of benefits and side effects, and should be reviewed after six months (SIGN 2004). Anticholinergic drugs are still the most widely used treatment for urgency and urge incontinence. However, current drugs lack selectivity for the bladder and effects on other organ systems may result in side effects, which limit their usefulness. For example, all anticholinergic drugs are contraindicated in untreated narrow angle glaucoma. The side effects of anticholinergics are listed in Table 2. Overflow incontinence This condition may occur as a result of urethral obstruction. One potential cause is prostate enlargement, which can occur in most men from about 40 years of age. One of the treatment options for this condition is the use of an alpha blocker such as tamsulosin, which relaxes the smooth muscle, producing an increase in urinary flow rate and an improvement in obstructive symptoms (Steggall 2007).

Treatment options
Recent developments in the management of overactive bladder have broadened the therapeutic TABLE 2 Common medications used to treat urge urinary incontinence and mixed urinary incontinence
Name Oxybutynin hydrochloride, tolterodine tartrate, propiverine. Solifenacin succinate, darifenacin. Mode of action Reduce detrusor overactivity; depress voluntary and involuntary detrusor contractions. M3-receptor selective antimuscarinics. Side effects/cautions Dry mouth, blurred vision, abdominal discomfort, drowsiness, nausea and dizziness. Dry mouth, blurred vision, constipation. Dry mouth, constipation, dry eyes, dry throat, indigestion.

Pharmacological therapy
Stress incontinence The main therapeutic option for stress incontinence is conservative treatment, although some patients may be prescribed alpha blockers such as tamsulosin. Duloxetine, a serotonin-noradrenaline (norepinephrine) re-uptake inhibitor, has been used in this setting and been found to increase quality of life. However, it is unclear if the benefits are sustainable in the longer term (Mariappan et al 2005). Urge incontinence The success of bladder retraining can be augmented by using a group of medications (anticholinergics) that help to relax NURSING STANDARD

Fesoterodine fumarate. Antimuscarinic.

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

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options for the treatment of incontinence. Pelvic floor retraining programmes have been beneficial and improved quality of life for some patients, for example those with detrusor overactivity who are unable to take anticholinergics because of side effects. The therapy is aimed at training the pelvic floor and external urethral sphincter muscles through producing a series of electrically-induced contractions to improve strength and function. For patients with idiopathic overactive bladder symptoms who fail to respond to pelvic floor retraining programmes and medical therapy, botulinum toxin type A is the next option. This acts at the neuromuscular junction to break down the intracellular proteins that aid in the release of acetylcholine into the synaptic cleft (Dolly 2003).

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

Conclusion
Urinary incontinence is a common and distressing problem. Nurses should attempt to identify and promote continence at every opportunity. Lifestyle modification in terms of drinking habits can help, but the underlying cause of incontinence needs to be identified accurately, assessed and treated. Nurses are able to encourage discussions designed to identify when continence problems occur and act as a resource both for intervention and for signposting for referral of individuals with severe problems. Treatment options include behavioural and/or pharmacological intervention. The aim of any intervention is to assist in curing or at least controlling the symptoms NS

References
Abrams P, Cardozo L, Fall et al (2002) The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourology and Urodynamics. 21, 2, 167-178. Abrams, P, Swift, S (2005) Solifenacin is effective for the treatment of OAB dry patients: a pooled analysis. European Urology. 48, 3, 483-487. Anderson KE (2004) Antimuscarinics for treatment of overactive bladder. The Lancet Neurology. 3, 1, 46-53. Andersson KE, Chapple C, Cardozo L et al (2009) Pharmacological treatment of overactive bladder: report from the International Consultation on Incontinence. Current Opinion in Urology. 19, 4, 380-394. Audit Commission (1999) First Assessment: A Review of District Nursing Services in England and Wales. Audit Commission, London. Australian Government Department of Health and Ageing (2007) Dementia and Urinary Incontinence. http://bit.ly/dtP4aS (Last accessed: September 8 2010.) Bernier F, Sims TW (2009) Management of clients with urinary disorders. In Black JM, Hawks JH (Eds) Medical-Surgical Nursing: Clinical Management for Positive Outcomes. Eighth edition. Elsevier Saunders, St Louis MO, 727-778. Chaliha C, Stanton SL (2002) Urological problems in pregnancy. BJU International. 89, 5, 469-476. Colbert B, Ankley J, Lee K, Steggall M, Dingle M (2009) Anatomy and Physiology for Nursing and Health Professionals: An Interactive Journey. Pearson Education, Harlow, 439-464. Cummings JM, Rodning CB (2000) Urinary stress incontinence among obese women. International Urogynecology Journal and Pelvic Floor Dysfunction. 11, 1, 41-44. Dallosso HM, McGrother CW, Mathews RJ et al (2003) The association of diet and other lifestyle factors with overactive bladder and stress incontinence: a longitudinal study in women. BJU International. 92, 1, 69-77. Dolly O (2003) Synaptic transmission: inhibition of neurotransmitter release by botulinum toxins. Headache. 43, Suppl 1, S16-S24. Getliffe K, Dolman M (1997) Promoting Continence: A Clinical and Research Resource. First edition. Baillire Tindall, Edinburgh, 21-52. Herbruck L (2009) Management of women with reproductive disorders. In Black JM, Hawks JH (Eds) Medical-Surgical Nursing: Clinical Management for Positive Outcomes. Eighth edition. Elsevier Saunders, St Louis MO, 912-939. Hunskaar S, Lose G, Sykes D, Voss S (2004) The prevalence of urinary incontinence in women in four European countries. BJU International. 93, 3, 324-330. Joanna Briggs Institute (2006) A pelvic floor muscle exercise programme for urinary incontinence following childbirth. Nursing Standard. 20, 33, 46-50. Karon, S (2005) A team approach to bladder retraining: a pilot study. Urologic Nursing. 25, 4, 269-276. Kelleher CJ, Cardozo LD, Khullar V, Salvatore S (1997) A new questionnaire to assess the quality of life of urinary incontinent women. British Journal of Obstetrics and Gynaecology. 104, 12, 1374-1379. Mariappan P, Alhasso AA, Grant A, NDow JMO (2005) Serotonin and noradrenaline reuptake inhibitors (SNRI) for stress urinary incontinence in adults. Cochrane Database of Systematic Reviews. Issue 3. National Institute for Clinical Excellence (2003) Infection Control. Prevention of Healthcare Associated Infections in Primary and Community Care. Clinical Guideline No. 2. NICE, London. National Institute for Health and Clinical Excellence (2006) Urinary Incontinence: The Management of Urinary Incontinence in Women. Clinical Guideline No. 40. National Collaborating Centre for Womens and Childrens Health, London. Neumann PB, Grimmer KA, Deenarayalan Y (2006) Pelvic Floor Muscle Training and Adjunctive Therapies for the Treatment of Stress Urinary Incontinence in Women: A Systematic Review. http://dx.doi.org/10.1186/ 1472-6874-6-11 (Last accessed: September 8 2010.) Sampselle CM, Harlow SD, Skurnick J, Brubaker L, Bondarenko I (2002) Urinary incontinence predictors and life impact in ethnically diverse perimenopausal women. Obstetrics and Gynaecology. 100, 6, 1230-1238. Scottish Intercollegiate Guidelines Network (2004) Management of Urinary Incontinence in Primary Care. National Clinical Guideline No. 79. SIGN, Edinburgh. Shaw C, Gupta RD, Bushnell DM et al (2006) The extent and severity of urinary incontinence amongst women in UK GP waiting rooms. Family Practice. 23, 5, 497-506. Southon L (2008) A dynamic approach to pelvic floor rehabilitation. Continence UK. 2, 2, 23-27. Steggall MJ (2007) Acute urinary retention: causes, clinical features and patient care. Nursing Standard. 21, 29, 42-46. The Continence Foundation (2000) Making the Case for Investment in an Integrated Continence Service. The Continence Foundation, London. Vella M, Cardozo L (2005) Urinary incontinence in the female patient. The Practitioner. 249, 1670, 345-352. Wagg A, Potter J, Peel P, Irwin P, Lowe D, Pearson M (2008) National audit of continence care for older people: management of urinary incontinence. Age and Ageing. 37, 1, 39-44.

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