This site is intended for health professionals only

Management of urinary incontinence in the community

Key learning points:

 - Breaking down patient misconceptions about incontinence

 - How guidelines can help plan management of incontinence

 - The role of nurses in primary care

Urinary symptoms should be assessed and managed in the community. With increasing pressure to provide more care closer to home, the expectations on nurses to deliver effective continence care cannot be met without relinquishing other areas. The challenge is prioritising continence high enough into working capacity to ensure that time spent treating urinary symptoms is productive and results in a better use of time and resources in the longer term. In reality, when clinical workload is greater than the time available, continence care is often only awarded the quickest and simplest intervention available - the incontinence pad. 

Establishing the prevalence of urinary symptoms is difficult. Loss of bladder control is not a subject which people are keen to either admit to or seek help for. A recent estimation of the prevalence of urinary symptoms in the UK was put at 34% of women.1 For men, estimations increase from 3% in men 40-44 years of age to 42% in those ≥75 years.2 The prevalence of urinary incontinence is higher in adults who have suffered nocturnal enuresis or daytime wetting as a child.3

There are a number of barriers that prevent help-seeking behaviour. For many individuals their expectations of treatment amount to incontinence pads. Making it clear that many symptoms can be improved with evidence-based interventions can be difficult. Symptoms are often considered not significant enough to bother a healthcare professional with, despite their devastating impacts upon quality of life.4 Advertisements for incontinence products normalise the condition and do little to encourage the individual to seek help to resolve symptoms. 

The causes of urinary symptoms are multifactorial. Risk factors in women include pregnancy, parity and childbirth, although these risk factors become less important with increasing age.5 Forceps in childbirth6 and urinary incontinence which develops during pregnancy and persists for more than three months postnatally is a prognostic indicator for long term continence problems,7 as are increasing maternal age and giving birth to babies of heavy birth weight.8,9 Menopause per se does not appear to be a risk factor for urinary incontinence, but there is conflicting evidence regarding hysterectomy. Diabetes Mellitus is a risk factor in most studies. Body mass index is a known risk factor.5

Risk factors in men include increasing age, lower urinary tract symptoms (for example straining to void, intermittent stream), urinary tract infection, neurological disorders, and prostatectomy.5

Being physically able to reach the toilet and having the cognitive ability to recognise and act on the signals of needing to empty the bladder and knowing where the toilet is may also contribute towards urinary incontinence. 

The various risk factors affect different parts of the bladder and result in different urinary symptoms.

For women, urinary symptoms can be categorised into three main groups:10

 1. Stress urinary incontinence - for example leaking urine when coughing, sneezing or laughing. 

 2. Urge urinary incontinence - for example needing to rush to the toilet often and urgently. 

 3. Mixed urinary incontinence (combination of stress and urge urinary incontinence).

For men, lower urinary tract symptoms can be categorised into three main groups:2

 1. Storage symptoms - for example urgency, daytime frequency, nocturia or urgency incontinence. 

 2. Voiding symptoms - for example hesitancy to void, intermittent/slow/spraying stream or terminal dribble. 

 3. Post-micturition symptoms - for example feeling of incomplete voiding or post-micturition dribble. 

It is fundamental that the nursing assessment leads to a provisional diagnosis of one of these categories. 

Assessment

The key to continence care lies in the accurate assessment. Guidelines exist to support the management of urinary symptoms in males and females: Scottish Intercollegiate Guidelines Network,11 and the National Institute of Health and Care Excellence (NICE).10,2 In order to be effective the basics must be in place. 

An initial assessment may include general medical history, identification of predisposing/precipitating factors for symptoms, relevant surgical history including obstetric and gynaecology history or prostatic history if appropriate, bowel symptoms, medication history, functional status, toilet access, and sexual function. It is important to consider how much of an impact upon quality of life the symptoms are having and what the individual wishes to achieve from any treatment. A thorough assessment will also highlight any 'red flag' symptoms, such as unexplained haematuria, or prostate problems, which will indicate the need for redirecting the patient to a specialist as soon as possible. At the end of the assessment the nurse should be able to categorise the symptoms, make a provisional diagnosis, and identify which treatment pathway to follow. 

A bladder diary is essential. The recommended duration of the diary varies for each guideline, with the minimum duration of at least 24 hours to a maximum of seven days. In clinical practice, a variation of three days is usually achievable and can be reflective of the patient's normal symptoms. The information required in this diary should include a record of fluid intake detailing the types of drinks taken, and if possible, the volumes of each drink, along with the time each drink was taken. A record of corresponding output is also required and should include the times the patient voids, and if possible the volumes of each void. The bladder diary can demonstrate poor drinking habits, bladder capacities, excessive daytime frequency, nocturnal polyuria, and any deficiency between intake and output. Without a bladder diary, care planning is futile; some of the basic causes for urinary symptoms can be addressed by examining the bladder diary and rectifying bad habits. 

Urinalysis should be used to rule out urinary tract infection. Treat as per local guidelines then reassess symptoms. Vaginal examination or digital rectal examination should be undertaken where appropriate.

Treatment pathways

The first step should be to address any contributing behaviours identified in the bladder diary. Lifestyle factors include:10

 - A trial of caffeine reduction for symptoms of overactive bladder. The exact action of caffeine upon the bladder is unknown but symptomatically caffeine can increase the sensation of urgency. 

 - Modifying high or low fluid intake.

 - Individuals with a body mass index greater than 30 should be advised to lose weight.

Treatments thereafter are based around the category of symptoms identified in the initial assessment. The treatment guidelines for the conservative management of women with urinary symptoms include:10,11

For symptoms of stress urinary incontinence:

A trial of supervised pelvic floor muscle training of at least three months' duration. It is recommended that physical examination of the pelvic floor muscles is carried out prior to the prescription of any exercise regime. Where the nurse does not have the skills to assess pelvic floor muscles, the patient should be referred to either a specialist continence nurse or physiotherapist.

For symptoms of urge urinary incontinence:

 - Bladder training lasting for a minimum of six weeks. The basis for planning toileting intervals stems from the information gained in the bladder diary.

 - For women who do not achieve satisfactory benefit from bladder training, the

combination of anticholinergic medication should be considered. 

 - In women with urge urinary incontinence who are cognitively impaired, prompted and timed voiding toileting programmes are recommended.

 - Intra-vaginal oestrogens are recommended for the treatment of overactive bladder symptoms in postmenopausal women with vaginal atrophy.

 - Where mixed urinary incontinence is reported, treatment should be directed at the predominant symptoms. 

Guidelines for conservative treatment of men include:2

For storage symptoms:

 - Offer supervised pelvic floor muscle training for stress urinary incontinence caused by prostatectomy. Continue the exercises for at least three months before considering other options.

 - Offer bladder retraining for symptoms suggestive of overactive bladder.

 - If bladder retraining fails, consider adding anticholinergic medication for symptoms of overactive bladder.

 - Offer an alpha blocker for moderate to severe symptoms. 

 - Or a combination of an alpha blocker and a 5-alpha reductase inhibitor to men with bothersome moderate to severe symptoms and prostates estimated to be larger than 30g or a PSA level greater than 1.4 ng/ml.

 - Consider offering an anticholinergic as well as an alpha blocker to men who still have storage symptoms after treatment with an alpha blocker alone. 

 - Offer temporary containment products until a diagnosis and management plan have been discussed.

Voiding symptoms:

 - Inform men with proven bladder outlet obstruction that bladder training is less effective than surgery.

 - Where symptoms indicate voiding dysfunction offer a serum creatinine test (plus estimated glomerular filtration rate calculation if you suspect renal Impairment. For example with a palpable bladder, nocturnal enuresis, recurrent urinary tract infections or a history of renal stones).

Post-micturition symptoms:

 - Explain to men with post-micturition dribble how to perform urethral milking.

 - For men and women with proven voiding dysfunction treatment options include bladder drainage using different modes of catheterisation.

 - The role of containment products, such as incontinence pads, has a place for some individuals, in some treatment pathways. However usage can lead to dependency upon pads which may in turn reduce motivation to try or adhere to treatments. 

Referral onto specialist services

Where conservative interventions fail to achieve satisfactory improvement, referral onto specialist services either within the community setting or in secondary care should be sought. For patients who do not wish to embark upon the recommended treatments, or for whom prescribed treatment programmes are inappropriate, containment products, such as incontinence pads, may be an option. 

Conclusion

In conclusion, given the evidence base supporting many treatments for incontinence, the challenge is not only to find time to deliver this area of care, but to educate and alter the expectations of the individuals who believe that continence treatment only equates to the provision of pads. The recurring costs which arise from the continued use of pads, instead of trailing conservative treatments are met by not only the budget holders, but the patients and their carers. Investing in accurate assessment and thereafter efficacious treatment programmes will result in longer-term savings in all aspects of life, not only for patients and carers, but also for nurses in the community.

 

References

1. National Institute of Clinical Excellence. Draft Update Urinary incontinence the management of urinary symptoms in women. London: RCOG press; 2011. 

2. National Institute of Clinical Excellence. The management of lower urinary tract symptoms in men. London: RCOG Press; 2010.

3. Kuh D, Cardozo L, Hardy R. Urinary incontinence in middle aged women: childhood enuresis and other lifetime risk factors in a British prospective cohort. J Epidemiology Community Health 1999;53(8):453-8.

4. Kinchen K, Burgio K, Diokno A, Fultz N, Bump R, Obenchain R. www.ncbi.nlm.nih.gov/pubmed/14583109. " target="_blank">Factors associated with women's decisions to seek treatment for urinary incontinence. J. Women's Health 2003;12(7):687-98. 

5. Thuroff J, Abramsa P, Andersson K, Artibani W, Chapple C, Drake M, Hampel C, Neisius A, Schroder A, Tubaro A. EUA guidelines on urinary incontinence. European Urology 2011;59:387-400. 

6. Van Kessel K, Reed S, Newton K, Meier A, Lentz G. The second stage of labor and stress urinary incontinence. Am Journal Obstetrics Gynaecology. 2001;184(7):1571-5.

7. Viktrup L, Lose G. The risk of stress incontinence five years after first delivery. Am Journal Obstetrics Gynaecol 2001;185(1)82-7.

8. Mason L, Glenn S, Walton I, Appleton C. The prevalence of stress incontinence during pregnancy and following delivery. Midwifery 1999;15(2):120-8.

9. Rortveit G, Hannestad Y, Daltveit A, Hunskaar S. Age- and type- dependent effects of parity on urinary incontinence: The Norwegian EPINCONT study. Obstet Gynaecol 2001;98(6)1004-10.

10. National Institute of Clinical Excellence. Urinary incontinence the management of urinary symptoms in women. London: RCOG press; 2006.

11. Scottish Intercollegiate Guidelines Network. Managing urinary incontinence in primary care. 2004.