Restore bladder control with nondrug treatment
By Ivy M. Alexander, MS, C-ANP
Adult Nurse Practitioner
Assistant Professor
Yale University School of Nursing
Adult and Family Nurse Practitioner Programs
New Haven, CT
Urinary incontinence (UI) affects 14% to 44% of women ages 30 to 60.1 It is associated with social isolation, reduced self-esteem, skin breakdown, infection, falls, and significant expense.2 Despite the prevalence and problems associated with UI, less than half of the women affected discuss UI with a provider. This lack of disclosure is likely due to embarrassment and lack of knowledge about potentially beneficial treatments.1,2 Those factors heighten the importance of sensitive questioning by providers to identify UI problems and share knowledge regarding treatment possibilities. The most commonly identified types of UI include:1-4
• Stress incontinence — incontinence with increased intra-abdominal pressure caused by coughing, sneezing, exercising, lifting objects, etc., associated with bladder sphincter dysfunction.
• Urge incontinence — incontinence following the urge to urinate, often from detrusor hyperactivity (overactive bladder).
• Mixed incontinence — symptoms of both urge and stress incontinence.
• Transient incontinence — acute onset incontinence, often from factors other than detrusor or sphincter dysfunction.
• Overflow incontinence — incontinence due to incomplete bladder emptying, often related to bladder rigidity or obstruction.
• Functional incontinence — caused by reduced mobility (inability to get to the bathroom or to remove clothing) or mental impairment (dementia, delirium, or depression).
Evaluation for UI focuses on identifying causes and guiding possible treatment. The his -tory focuses on understanding the onset, duration, and patterns of incontinence. Questions to identify signs of neurological impairment (stroke, brain tumor, Parkinson’s disease, multiple sclerosis, or trauma), potential psychological causes, and other factors such as surgical history, bowel habits, and medications also are included. If voiding symptoms and patterns are unclear, a voiding diary documenting patterns and amounts of fluid intake, voiding, and incontinence can be helpful.
The exam includes a neurologic assessment especially evaluating sacral reflexes and perineal sensation. The pelvic and abdominal exam identifies atrophic changes, bladder distention, pelvic muscle strength, and uterine, rectal, or bladder prolapse. A rectal exam can identify constipation and rectal sphincter strength.2-5
Initial lab evaluation should rule out infection and systemic causes of polyuria. That includes urinalysis and urine culture to identify hematuria, glucosuria, bacteria, low specific gravity, and serum BUN, creatinine, glucose, and calcium.2-4 Additionally, a post-void residual urine is recommended by the Agency for Health Care Policy and Research, now the Agency for Healthcare Research and Quality (AHRQ). How ever, others reserve that and urodynamic testing for referral.3,4
Providers usually can identify causes for transient incontinence by using the "DIAPPERS" mnemonic device:5
D delirium (acute, not dementia);
I infection;
A atrophic vaginitis;
P pharmaceuticals (diuretics, antihypertensives, antidepressants, or anticholinergics);
P psychological issues (such as neglect or depression);
E excessive urine production (high fluid intake, caffeine, alcohol, hypercalcemia, hyperglycemia, diuretics, medical conditions predisposing nocturnal output such as congestive heart failure and peripheral vascular disease);
R reduced mobility (arthritis, pain, or fracture);
S stool impaction.
Review options
The AHRQ guidelines identify behavioral treatment as the first line intervention for UI.3 Urge, stress, and mixed incontinence — the most common types of UI among women1 — all respond well to these modalities.2-8
• Bladder training. The goal is to establish a three- to four-hour voiding interval. Baseline voiding frequency is identified using the history or voiding diary. Positive reinforcement is provided for women with normal frequency. In women with shorter intervals, increases of 15 to 30 minutes are added every week or two. Methods for increasing intervals include mental distraction (reading, counting backward, or writing a letter), relaxation (deep breathing, slowly exhaled), sitting still, and flexing pelvic muscles when the urge to urinate is felt. Women can monitor their own progress using a voiding diary.
• Pelvic muscle exercise (PME). PME can improve pelvic muscle strength and control. Pelvic muscles are contracted and held for five to 10 seconds, then relaxed for 10 seconds repeatedly, building up to a 10-minute exercise period followed by several quick flexes of the muscles.
Identifying the correct muscles for contraction can be difficult, so suggestions such as using the same muscles to interrupt urine flow or to avoid passing intestinal gas can help. It is important to avoid bearing down as this can increase UI. Clinicians can teach women to recognize and avoid this by having the woman practicing bearing down while in the office.
Learning PME takes concentration and time, so suggesting it can be accomplished "anywhere" or "anytime" is misleading. Women should be encouraged to set aside time for PME when they can concentrate. Personal reminders such as a sticky note on their mirror or a special magnet on the refrigerator can help with reinforcing regular exercise. If the routine lapses, the usual routine should be restarted rather than attempting to catch up. Vaginal weights can be used after baseline strength has been established.
• Urge suppression. Urge suppression helps control urgency sensations. The woman should sit quietly, relax, or contract the pelvic muscles until the urge passes, then proceed to the bathroom at a normal pace. This is often considered part of bladder training, but it can be a useful intervention for women with urge incontinence who have a normal voiding frequency.
Behavior techniques are successful in reducing UI by 50% to 90%.2-6 They have been more successful than medication therapy7 and remain effective over time.8 Self-assessment by reviewing personal voiding diaries can motivate women to continue these techniques. Positive reinforcement and ongoing assessment by providers also can increase motivation and is needed to identify changes that may indicate a need for further evaluation.
References
1. Hampel C, Wienhold D, Benken N, et al. Definition of overactive bladder and epidemiology of urinary incontinence. Urology 1997; 50(suppl 6A):4-14.
2. Krissovich M, Safran R. Urinary incontinence in adults. Lippincott’s Primary Care Practice 1997; 1:361-1,381.
3. Fantl JA, Newman DK, Colling J, et al. Urinary Incontinence in Adults: Acute and Chronic Management. Clinical Practice Guideline, No. 2, 1996 Update. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service; AHCPR publication no. 96-0682.
4. Butler RN, Maby JI, Montella, JM, et al. Urinary incontinence: Primary care therapies for the older woman. Geriatrics 1999; 54:31-44.
5. Resnick NM. Urinary incontinence in the elderly. Hosp Prac 1986; Nov 15:80c-80x.
6. Sampselle CM, Burns PA, Dougherty MC, et al. Continence for women: Evidence-based practice. JOGNN 1997; 26:375-385.
7. Burgio KL, Locher JL, Goode PS, et al. Behavioral vs. drug treatment for urge urinary incontinence in older women. JAMA 1998; 280:1,995-2,000.
8. O’Brien J. Evaluating primary care interventions for incontinence. Nursing Standard 1996; 10:40-43.
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