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Urinary incontinence: current best management

Alison Bardsley
RGN DipDN
Continence Advisor/Service Manager Oxfordshire
Chair RCN Continence Care Forum
T:01993 209434

An average adult bladder can hold between 350 and 500ml of urine. The bladder fills with urine with a minimal change in pressure until it is about half full, when signals are sent to the brain. Voiding is controlled by the pontine micturition centre in the brain, and involves coordination of detrusor (bladder muscle) contraction and urethral relaxation. The desire to void can be suppressed until it is convenient, when the brain responds and the bladder contracts. At the same time the muscles within the bladder neck and urethral sphincter relax, allowing the bladder to empty. The bladder consists of smooth muscle innervated by the parasympathetic cholinergic nerve supply, which leaves the spinal cord at S2-4.
Urinary incontinence is defined as: "The involuntary or inappropriate passing of urine and/or faeces that has an impact on social functioning or hygiene."(5) Dysfunction of the anatomy, neurology and physiology of the bladder and urethra can affect the ability of the bladder to store urine, leading to urinary incontinence.

Presenting problems

Weakness of the muscles at the urinary outlet (stress incontinence)

Although women can suffer from any type of incontinence, stress incontinence occurs predominantly among females. The prevalence of stress incontinence is highest amongst the 15-44 age group, with up to 1 in 20 women affected,(5) mainly due to pregnancy, childbirth and hormonal changes approaching the menopause. Stress urinary incontinence is the involuntary loss of urine, associated with a rise in intra-abdominal pressure (exerted on the bladder), on, for example, exertion, coughing and sneezing.(6,14)
Failure of the sphincter muscle at the bladder neck (an integral part of the pelvic floor muscle) to maintain complete closure under pressure can cause stress incontinence.
Weakened smooth urethral muscle, supporting ligaments and striated pelvic floor muscles can be due to damage to the tissue concerned (eg, from multiple parity, prolonged difficult labour, perineal trauma and surgery). Men can suffer from stress incontinence following prostate surgery or trauma (such as pelvic injuries) where the sphincter muscles become damaged.

Detrusor instability (overactive bladder) or urge incontinence
Men and women present equally with detrusor instability. Causes are varied but include neurological lesions, such as those resulting from spinal cord injuries, stroke, multiple sclerosis, diabetes and Alzheimer's disease. Loss of the inhibitory impulses from the brain results in inappropriate contractions of the bladder, which can occur spontaneously or with provocation (eg, coughing or vigorous exertion).(6) These contractions lead to frequent urgency to void with little or no warning, often resulting in incontinence.

Voiding difficulties caused by outflow ­obstruction or detrusor hypoactivity
Outflow obstruction is more common in men than women, and is most often associated with prostatic enlargement (increasing in men over 45 years), urethral stricture and constipation. The bladder is emptied with frequent voiding of small amounts, associated with hesitancy and poor urine flow. Patients report symptoms of frequency, urgency and nocturia, while dribbling can occur if large residuals are present.(6)
In detrusor hypoactivity the bladder muscle is under-active and cannot provide a sustained or adequate contraction in order to empty. This is usually caused by damage to the bladder nerve supply (such as in spinal injuries and pudendal nerve damage during childbirth). Sensation of bladder filling may be absent or reduced, and bladder capacity often increases due to overstretching.(6)

Assessment of incontinence
Many disciplines come into contact with people with continence problems, and all should be aware of the need to ask appropriate questions and allow patients to discuss any problems. Staff should be sensitive to cultural and ethnic differences in language used by patients to describe their problems. The first point of contact for most patients remains within primary care, for example their GP, community or practice nurse.(7-9)
Within primary care, many patients can be treated on the basis of their presenting symptoms without detailed investigation or tests. A baseline chart of voiding frequency, bladder volumes, fluid intake (type and amount) and number of wetting episodes provides a record to enhance a patient's verbal history. Improvements should be regularly monitored (every 2-4 weeks). If no improvement is seen, referral to a specialist continence advisor or physiotherapist should be made.
A urinalysis should be undertaken for all patients presenting with urinary symptoms to exclude urinary tract infection (UTI), blood in the urine, or signs that may indicate underlying conditions such as glucose in the urine (diabetes). For patients with suspected UTIs this should be treated before continuing with the assessment. Signs of blood in the urine with an unknown cause require further investigation and should be referred to a medical colleague (eg, urologist). Nurses can use trigger statements to prompt patients.(10)

Positive responses indicating symptoms of stress incontinence

  • I leak when I laugh, cough, run or jump.
  • I only leak a little urine.
  • At night, I need to visit the toilet only once or not at all.
  • I always know when I have leaked.
  • I leak without feeling the need to empty my ­bladder.
  • Only my pants get wet when I leak (not outer clothing), or I sometimes wear a panty liner.

Positive responses indicating symptoms of detrusor instability or urge incontinence

  • I feel a sudden strong urge to pass urine and to go quickly.
  • I feel a strong uncontrolled need to pass urine before leaking.
  • I leak moderate amounts of urine before I reach the toilet.
  • I feel that I pass urine frequently.
  • I think I had bladder problems as a child.

Positive responses indicating symptoms of ­outflow obstruction or detrusor hypoactivity

  • I find it hard to start to pass urine.
  • I have to push or strain to pass urine.
  • My urine flow stops and starts several times.
  • My urine stream is weaker and slower than before.
  • I feel that it take me a longer time to empty my bladder.
  • I feel as if my bladder is not completely empty after I have been to the toilet.
  • I leak a few drops of urine onto my underwear just after I have passed urine.

Treatments options for incontinence

Lifestyle modification measures
Lifestyle changes depend on the type of urinary symptoms experienced. Although advice regarding lifestyle modification is often successful in relieving the symptoms of urgency and frequency associated with detrusor instability, they are less effective in stress incontinence. Lifestyle modifications may include changes to fluid intake (eg, reducing caffeine intake), dietary changes such as increasing fibre to prevent constipation, weight loss and smoking cessation advice. However, these are unsuitable if the patient is unmotivated. Bladder retraining is used to help patients to "hold on" before voiding. It requires the patient waiting an increasing length of time before voiding, even if leakage occurs. Bladder retraining is often more successful in conjunction with drug therapy.

Pelvic floor exercises
Pelvic floor training consists of exercises to strengthen the pelvic floor muscles. Pelvic floor exercises have been shown to be effective in strengthening the muscles that contribute to the sphincter closure mechanism and provide support for the bladder and urethra.
Weighted vaginal cones and biofeedback can be used in conjunction with pelvic floor exercises. Pelvic floor exercises require motivation and commitment from the patient, as they need to be performed regularly during the day and continued long term in order to maintain the effects. Patients can become disillusioned as it can take up to 15 weeks before benefits are noticed. A vaginal examination is generally indicated to assess whether patients are performing the exercises correctly, and nurses need to be confident in order to teach pelvic floor exercises effectively.
For patients who do not respond to pelvic floor exercises, surgery may be an option, although the results can never be guaranteed. There are several well-established surgical options, including retropubic procedures, sling procedures and tension-free vaginal tape, which assist the pelvic floor muscles by lifting or supporting the bladder neck.

Medication

Detrusor instability
Most symptoms of detrusor instability can be improved using drug therapy. Detrusor muscle contraction is instigated by acetylcholine. The effect of acetylcholine on muscarinic receptors within the bladder wall can be inhibited by antimuscarinic drugs, causing a reduction in the contractions of the bladder.
Antimuscarinic drugs can also affect smooth muscle elsewhere in the body, such as the salivary glands and bowel, leading to a dry mouth and risk of constipation, and are therefore unsuitable for some patients (eg, those with glaucoma and intestinal atony).
Symptoms of frequency and urgency may also occur in patients with neurological problems or outflow obstruction (eg, multiple sclerosis, prostate enlargement and spinal injury), and may in these cases be due to an inability of the bladder to contract adequately, leading to residual urine. An assessment of residual urine should therefore be undertaken before commencing antimuscarinic drugs for patients with neurological problems.

Stress incontinence
Although no pharmacological options are currently available, approaches are being developed, such as Duloxetine (Eli Lilly). Studies have indicated that around 11% of women can become completely "dry" while taking Duloxetine, and 74% reported an improvement of symptoms.(11,12)

Outflow obstruction
Benign prostate hyperplasia is the most common cause of outflow obstruction in men. Drug therapy such as alpha-blockers can improve both filling and voiding symptoms by relaxing smooth muscle and reducing urethral resistance.(13) However, caution is recommended with older men and those on antihypertensive medication due to side-effects such as postural hypertension and dizziness.
Another option is the use of 5-alpha-reductase inhibitors (eg, finasteride) to shrink the epithelial part of the prostate gland, by suppressing the principal agent that causes prostate enlargement.

Conclusion
Urinary incontinence is a common condition among both men and women of all ages, but also one that can be cured (around 70% of cases) or significantly improved.(2) Nurses working in primary care are ideally placed to identify, assess and treat people with continence problems. Nurses need to discuss treatment options and involve the patient in planning their treatment programme in order to gain the patient's trust and motivate them.

References

  1. Perry S, et al.J?Public Health Med2000;22:427-34.
  2. Royal College of Physicians. Incontinence: causes,management and provision of services. London:  RCP; 1995.
  3. White H, Getcliffe K. Incontinence in perspective. In: Getcliffe K, Dolman M, editors. Promoting ­continence. A clinical research resource. London: Baillière Tindall; 2003. p. 1-21.
  4. Thomas T, et al. Br J Surg 1985;72:141.
  5. Department of Health. Good practice in ­continence ­services. London: TSO; 2000.
  6. Abrams P, et al.  2nd International Consultation on Incontinence. Paris; July 2002.
  7. Benson L, et al. J Nurs Manag 2001;9:213-20.
  8. Rigby D. Nurs Stand 2001;16:46-52.
  9. Audit Commission. First assessment: a review of district nursing services in England and Wales. London: AC; 1999.
  10. Bayliss V, et al. Br J Nurs 2000;9:590-2.
  11. Resnick N, Griffiths D. JAMA 2003;290:395-7.
  12. Anderson KE, et al. Pharmacological treatment of urinary ­incontinence. In: Abrams P, et al. 2nd International Consultation on Incontinence. Paris; July 2001. p. 573-624.
  13. Fenele RCL, Gingell JC, et al. Urology ­guidelines for GPs. Urological Institute, Bristol.
  14. Getcliffe K, Dolman M. Promoting ­continence:a clinical research resource. London: Baillière Tindall; 2003.