1. SPPICES: Urinary Incontinence

2. Organizational Goal
To organize continence services in an integrated fashion that focuses on the identification of patients, assessing their condition and implementing the most appropriate treatment plan. This model of good practice will allow staff to achieve more responsive and effective continence services and assist patients.

3. SPPICES Questions
Do you have problem passing water/getting to the bathroom on time?
Did you wear incontinence products at home?
If there is a catheter, is it still needed?
Was your last bowel movement 3 days ago?

4. Did you know that... 50% - 70% of persons with UI don’t seek help.
UI is a very common problem with treatments that work.
Most cases of UI can be markedly improved.
Reasons for not seeking help unclear but linked to:
too embarrassed
hope it will improve without intervention
normal part of aging and / or nothing can be done
afraid of needing an operation
don’t perceive it as s serious problem compared to those who seek help

5. Prevalence 15% - 30% of seniors in the community
15.3% in acute care facilities
50% in nursing homes
15% = males; 30% = females
rates vary between 8-51% because of: closet issue - too embarrassing to report
unsure of true extent % of people don’t seek help
problems with research (some use subjective report, white women, depends how question asked, varying levels of incontinence

6. Impact of UI Physical Psychosocial Financial Physical falls, fractures
urosepsis
skin breakdown
Psychosoocial
social isolation
embarrassment, feelings of shame
loneliness
stress on family/ caregiver
Financial
affects discharge from hospital or acceptance to RH, rehab
one study found 44% of families who institutionalized their loved ones cited difficulty managing continence as reason for admission
impact on family - children - sons
increase time for care in hospital/NH
cost of incontinent pads, briefs, laundering, catheters

7. Definition
A common, disruptive, and potentially disabling condition in the aging population.
An involuntary loss of urine in sufficient amounts or frequency to constitute a social and/or health problem.
(Kane, Ouslander, & Abrass, 1994)
Key is
social/ health problem
self described

8. Requirements for Continence
Effective lower urinary tract functioning  storage & emptying
Adequate mobility and dexterity to use the toilet, toilet substitute, and to manage clothing
Adequate cognitive function to recognize toileting needs and to find a toilet/substitute
Motivation to be continent
Absence of environmental and iatrogenic barriers such as inaccessible toilets/substitutes, unavailable family/caregivers and drug side effects

9. Established/Persistent UI: The Bladder
Normal Aging Changes
Anatomy
Physiology
Aging itself does not cause UI!!
Aging does contribute to:
Decrease in bladder capacity
Increase in residual urine
Involuntary bladder contractions
A 30%-40% loss of functional cells in the kidneys (nephrons)
A decrease in the kidney’s ability to filter blood and concentrate urine
Wearing out of the sensory nerve tract from brain to bladder
and these can put people at greater risk of UI
Decrease in bladder capacity – leading to the bladder not emptying fully leading to increase in frequency and residual urine leading to UTIs from the urine left in the bladder
Bladder spasms create the “sensation to void” before the bladder is full leading to urge incontinence while patients are walking to the bathroom
Men ~ prostatic enlargement causes a decrease in urine flow & detrusor motor instability
Women ~ decline in bladder outlet and urethral resistance pressure

10. Types of UI Acute / Reversible
Established/Persistent Overflow Urge Functional Stress

11. Causes of Acute/Reversible UI
D Delirium
I Infection
A Atrophic Vaginitis/ Urethritis
P Pharmaceuticals
P Psychological causes
E Excess fluid
R Restricted mobility
S Stool impaction
(Resnick, 1992)
List of causes:
Delirium/confusional state
Infection - 30% of hospitalized seniors have asymptomatic bacteruria. Ouslander (1992) recommended that incontinent elderly pts with significant bacteruria be considered symptomatic vs. asymptomatic
Atrophic vaginitis - results from low estrogen levels in postmenopausal women
pharmacueticals - caffeine, diuretics, sedatives/hypnotics, narcotics, anticholinergics, calcium channel blockers all can contribute
psychological causes - depression, anger, hostility toward caregiver, regression in psych pts
excess fluids - from high fluid intake (esp caffeine) or from volume overload with venous insufficiency or CHF endocrine problems like hyperglycemia and hypercalcemia both cause polyuria and can also trigger incontinence
restricted mobility - surgery, fracture, restarints, arthritis, neuro
stool impaction - causes outlet obstruction has been cited as a primary cause of incontinence occurring in 5-10% of frail NH pts

12. Established UI: Overflow
Urine loss (dribbling) associated with an overdistended bladder due to an obstruction in the urethra.
Signs and Symptoms:
Leakage of small amounts of urine
Palpable or percussable bladder, suprapubic tenderness
Hesitancy on voiding, interrupted urine flow or post void dribbling
Urine loss without urge
Sensation of incomplete voiding or bladder fullness
Frequency
This implies that the bladder cannot empty completely, retains urine, becomes overdistended, and then overflows.
It is characterized by the constant leakage of small amounts of urine from a filled bladder.
Causes:
outlet obstruction: prostatic hypertrophy, fecal impaction, urethral stricture, pelvic organ prolapse (cystocele)
chronic myogenic decompensation: peripheral neuropathy (DM, spinal cord injury, MS)
acontractile, hypotonic, or underactive detrusor d/t anything that overdistends the bladder
pt with 2000 cc emptied from bladder

13. Established UI: Urge
Involuntary loss of urine (usually larger amounts) associated with a sudden, strong desire to void.
Signs and Symptoms:
Sudden “urgency” to void
Nocturia and / or Enuresis
Moderate to large amounts of urine loss
Loss of urine at the sound of water running or when waiting to access a public toilet
Nocturia = excessive urination at night; it may occur in older people who have excess fluids that are mobilized when theylie down at night
Enuresis = incontinence of urine, especially in bed at night
- unlike stress incontinence where small amount of urine lost, urge incontinence usually involves larger amounts
Causes:
lower urinary tract = UTI, cystitis, bladder tumour, bladder stones, urethritis, atrophic vaginitis
central nervous system = CVA, dementia, Parkinsons, NPH, MS
above result in uninhibited detrusor contractions
these can also be caused by deconditioned voiding reflexes (ie frequent voiding to reduce risk of incontinence) - this reduces bladder capacity and with time the bladder wall thickens, aggravating the condition of decreased tone and increased instability
incont d/t inhibited detrusor contractions in the absence of a neurological disorder is also called detrusor motor instability
Usually caused by an “unstable bladder” or “detrusor instability” isolated or associated with CNS disorders.

14. Established UI: Functional
Urinary leakage associated with the inability to toilet because of impairments in cognition and/or physical functioning, psychological unwillingness or environmental barriers.
Signs and Symptoms:
Report of being unable to get to the bathroom on time
Total emptying / large amounts of urine leakage
No incontinence when access to a bathroom and assistance with toileting available
Causes:
Evidence of impaired mobility, manual dexterity, communication or cognitive skills
Depression, anger, hostility
Physical and/or chemical restraints

15. Established UI: Stress
An involuntary loss of urine (usually small amounts) with increases in intraabdominal pressure (ie. Cough, laugh, sneeze, exercise).
Signs and Symptoms:
Small amounts of urine leakage/loss associated with activity, lifting, coughing, sneezing, and/or laughing
Urine leakage during the day while person is active
Most common type of UI in women, less frequent in men
Causes:
incompetent urethra
weak pelvic floor musculature
Women – multiple childbirths, estrogen deficiency, trauma to external urinary sphincter
Men – pelvic trauma or sphincter damage during prostatectomy
Obesity
Smoking with chronic coughing
Pathophysiology
losses of small amounts of urine in the absence of a detrusor contraction usually during sudden increases in intra-abdominal pressure (from coughing, sneezing, etc).
The underlying cause is the inability of the urethra to sustain pressure that exceeds that of the bladder, particularly under exertional events

16. Interventions Environmental Alterations Lifestyle Management
Scheduling Regimes
Pelvic Muscle Rehabilitation
Continence Products
Catheterization
Occlusive & Pelvic Organ Support Devices
Medication
Surgery
Intervention based on type of incontinence, severity and impact on life, pts cog and functional status, pt/caregivers preferences and expectations, cost-benefit factors
assessment - voiding record, PVR
Environmental Alterations - lighting, commode/urinal by bed, skirts vs pants for women; zippers vs. buttons; RTS; loose fitting clothes
Lifestyle Management - reducing caffeine intake, weight reduction in obese people, reduce smoking to reduce chronic cough, prevent constipation through diet and exercise
Scheduling Regimes- timed voiding, habit training, prompted voiding, bladder training
Pelvic Muscle Rehabilitation - pelvic muscle exercises, vaginal weight training, biofeedback, electrical stimulation
Continence Products
Catheterization
Occlusive & Pelvic Organ Support Devices - penile compression devices, pessaries (for pelvic organ prolapse)
Medication - estrogen, oxybutinin
Surgery PT
proper skin care

17. URGE STRESS FUNCTIONAL
New onset urinary incontinence
Risk factors identified: Delirium/confusion
Infection, urinary symptoms
Atrophic vaginitis/urethritis
Pharmaceuticals
Psychologic disorders
Endocrine disorders
Restricted mobility
Stool impaction
Frequency
Noctuira
Enuresis
Moderate to large amount of urine loss
Frequent urination
Post void dribbling
Retention
Hesitancy
Sensation of fullness/pressure in abdomen
Urine loss without urge
Unable to get to toilet on time
Small amount urine loss
Associated with activity,
Coughing
Sneezing
Bladder training
Kegel exercises
Liners/briefs if needed
Environmental modifications
Consider medical referral as indicated
Provide urinal/commode
Subjective/objective report of improvement
Decreased use of liners/briefs
Kegel exercise
Bladder diary to establish routine
Monitor weekly
Subjective report of  in incontinent episodes
Allow patient sufficient time to void
Encourage double void
PVR using bladder scanner
Contact MD if appropriate for I/O or catheterization order
Provide urinal or commode
Medication review
PVR
Monitor daily then weekly
Scheduled toileting
Avoid restraints
Ensure toilet accessible
Provide commode etc at bedside
Modify fluid intake pattern
Modify environment eg remove obstacles
Ensure adequate lighting
OT/PT assessment
Monitor weekly
Subjective/objective report of  in incontinence episodes
Clinical Assessment
Symptoms
Interventions
Evaluation
Type of Incontinence
URGE
STRESS
OVERFLOW
FUNCTIONAL

18. Case Study
Mr. Yeung is a 90 year old man with a history of dementia, CHF, and osteoarthritis. He is on 40mg lasix BID, and Tylenol # 3 prn for his pain. During his hospitalization for exacerbation of his CHF, he has a new onset of urinary incontinence.
What type of UI is Mr. Yeung experiencing?
What would be your plan of action for him?
What meds is he on?
Is he constipated?
Is his intake adequate?
What’s his level of cog. Fx r/t dementia?
Does he have a UTI?
Does he have any mobility problems preventing him from getting to the toilet?
Is he retaining urine?
CLUES…Lasix, PVR = 30cc. Urine neg., bowel Normal, patient is not aware of when he needs to void or where the BR is, he is having difficulty getting to the BR
MR. JONES HAS FUNCTIONAL INCONTINENCE!!
Interventions
OT to Ax cog. Fx; ability to find BR, remember where it is, ability to pull pants up/down and safety issues/barriers in environment
PT to Ax mobility and ability to get on/off toilet safely
Nursing to start voiding record to establish his normal voiding pattern
Nursing to begin scheduled toileting routine Q2-4 H on days and Q4-6 on nights, or one that matches patient’s normal routine at home or as assessed from record
OT/PT/Nursing attempt to get patient to use urinal if possible as assessed via cog.fx Ax by OT