Overview of Urinary

Incontinence (UI) in the

Long Term Care Facility

Evaluation and Management

Ann M. Spenard RN, C, MSN
Courtney Lyder ND, GNP
 Learning Objectives
 Describe common reversible causes of UI
 Differentiate between chronic types of UI and
describe appropriate treatment options for each
diagnosis
 Describe evaluation procedures, which are
appropriate for establishing diagnosis of UI in
the long-term care setting
 Describe the process for completing the UI
Physical Assessment and History Form
 Describe all the components for completing the
physical examination for urinary incontinence
 Steps to Continence

1. Complete Physical Assessment and

History form
2. Determine the type of urinary
incontinence
3. Complete Algorithm
Evaluation is the Key!

Identification of the type of

urinary incontinence is the
key to effective treatment.
 History

Obtaining an accurate and

comprehensive UI History
Prevalence of Urinary Incontinence

 Estimated 10% to 35% of adults

 > 50% of 1.5 million nursing home
residents
 A conservative estimated cost of $5.2
billion per year for urinary incontinence
in nursing homes

Fant et.al. Managing Acute and Chronic Urinary Incontinence. Rockville, MD Agency for Health Care Policy and
Research. 1996. AHCPR Publication No. 90-06 National Center for Health Statistics. Vital Health Statistics Series.
13(No. 102). 1989e in
Impact on Quality of Life
 Loss of self-esteem
 Decreased ability to maintain independent
lifestyle
 Increased dependence on caregivers for
activities of daily life
 Avoidance of social activity and
interaction
 Restricted sexual activity

Grimby et al. Age Aging. 1993; 22:82-89.

Harris T. Aging in the Eighties: Prevalence and Impact of Urinary Problems in Individuals Age 65 and Over. Washington
DC: Dept. of Health and Human Services, National Center for Health Statistics, No 121, 1988.
Noelker L. Gerontologist. 1987; 27:194-200.
 Consequences of UI
 An increased propensity for falls
 Most hip fractures in elders can be traced
to nocturia especially if combined with
urgency
 Risk of hip fracture increases with
 physical decline from reduced activity
 cognitive impairments that may accompany a UTI
 medications often used to treat incontinence
 loss of sleep related to nocturia
 Risk Factors

 Aging
 Medication side effects
 High impact exercise
 Menopause
 Childbirth
 Factors Contributing to
Urinary Incontinence
 Medications  Diet
 Diuretics  Caffeine
 Antidepressants  Alcohol
 Antihypertensives
 Hypnotics  Bowel Irregularities
 Analgesics  Constipation
 Narcotics  Fecal Impaction
 Sedatives
Age Related Changes in the
Genitourinary Tract
 Majority of urine production occurs at
rest
 Bladder capacity is diminished
 Quantity of residual urine is increased
 Bladder contractions become
uninhibited (detrusor instability)
 Desire to void is delayed
 Types of Urinary Incontinence

 Stress
 Urge
 Mixed
 Overflow
 Total
 Types of Urinary Incontinence

 Stress: Leakage of small amounts of

urine as a result of increased pressure
on the abdominal muscles (coughing,
laughing, sneezing, lifting)
 Urge: Strong desire to void but the
inability to wait long enough to get to a
bathroom
 Types of Urinary
Incontinence (continued)

 Mixed: A combination of two types,

stress and urge
 Overflow: Occurs when the bladder
overfills and small amounts of urine
spill out (bladder never empties
completely, so it is constantly filling)
 Total: Complete loss of bladder control
 Remember...

Urinary Incontinence can

be treated even if the
resident has dementia!!
 Cause of Stress Urinary
Incontinence

 Failure to store secondary to urethral

sphincter incompetence
 Causes of Urge Urinary
Incontinence
 Failure to store, secondary to bladder
dysfunction
 Involuntary bladder contractions
 Decreased bladder compliance
 Severe bladder hypersensitivity
 Stress Incontinence vs. Urge
Incontinence: System Check List

Symptoms Stress Urge

Incontinence Incontinence
Urgency accompanies incontinence NO YES
(strong, sudden desire to void)
Leaking during physical activity (e.g. YES NO
coughing, sneezing, lifting, etc.)
Ability to reach the toilet in time, YES NO
following an urge to void
Waking to pass urine at night SELDOM OFTEN
 Causes of Mixed Urinary
Incontinence

 Combination of bladder overactivity

and stress incontinence
 One type of symptom (e.g., urge or
stress incontinence) often predominates
 Symptoms of Overactive
Bladder
 Urgency
 Frequency
 Nocturia, and/or urge incontinence
 ANY COMBINATION - in the absence
of any local pathological or metabolic
disorder
 Causes of Overflow Urinary
Incontinence
 Loss of urine  Outlet obstruction
associated with  Enlarged Prostate
over distention of  Urethral Stricture
the bladder  Fecal Impaction
 Failure to empty  Neurological Conditions
 Underactive bladder  Diabetic Neuropathy
 Vitamin B12  Low Spinal Cord Injury
deficiency  Radical Pelvic Surgery
 Neurogenic Bladder

What is a neurogenic bladder?

 A medical term for overflow
incontinence, secondary to a neurologic
problem
 However, this is NOT a type of urinary
incontinence
Basic Types and Underlying
Causes of Incontinence
Type Definition Causes
Stress Loss of urine with increase in intra- Weakness and laxity of
abdominal pressure (coughing, pelvic floor musculature,
laughing, exercise, standing, etc.) bladder outlet or urethral
sphincter weakness
Urge Leakage of urine because of Detrusor muscle instability,
inability to delay voiding after hypersensivity associated
sensation of bladder fullness is with local genitourinary
perceived conditions or central
nervous system disorders
Overflow Leakage of urine resulting from Anatomic obstruction by
mechanical forces on an over prostate, stricture,
distended bladder, or from other cystocele, acontractile
effects of urinary retention on bladder, detrusor-sphincter
bladder and sphincter function dyssynergy
Mixed Urinary leakage associated with Severe dementia, other
inability to toilet because of conditions that cause
impairment of cognitive and/or severe immobility, and
physical functioning, unwillingness, psychological factors
or environmental barriers
Reversible or Transient Conditions
That May Contribute to UI
“D” Delirium
Dehydration*
“R” Restricted mobility Retention
“I” Infection
Inflammation
Impaction
“P” Polyuria
Pharmaceuticals
 *Dehydration
 Dehydration due to decreased fluid intake;
increased output from diuretics, diabetes,
or caffeinated beverages; or increased fluid
volume due to congestive heart failure can
concentrate the urine (increased specific
gravity) and also lead to fecal impaction
 The specific gravity of the urine can be
tested to determine whether or not the
resident is dehydrated
 Basic Evaluation

 Physical Exam
 Female genitalia abnormalities
 Rectocele
 Urethral Prolapse
 Cystocele
 Atrophic Vaginitis
 Basic Evaluation for
Differential Diagnosis
 Patient History
 Focus on medical, neurological, genitourinary
 Review voiding patterns and medications
 Voiding diary
 Administer mental status exam, if appropriate
 Physical Exam
 General, abdominal and rectal exam
 Pelvic exam in women, genital exam in men
 Observe urine loss by having patient cough vigorously
Basic Evaluation for Differential
Diagnosis (continued)
 Urinalysis
 Detect hematuria, pyuria, bacterimia,
glucosuria, proteinuria
 Post void residual volume measurement by
catheterization or pelvic ultrasound
 Lab Results
 Lab results from approximately the last 30
days:
 Calcium level normal 8.6 - 10.4 mg/dl
 Glucose level normal fasting 65 - 110 mg/dl
 BUN normal 10 - 29 mg/100 ml (OR)
 Creatinine normal 0.5 - 1.3 mg/dl
 B12 level (within the last 3 years) normal 200 -
1100pg/ml

*Normal lab values may vary depending on laboratory used.

 Three Day Voiding Diary
 Three day voiding diary should be
completed on the resident
 Assessment should be completed 24
hours a day for 3 days
 Make sure CNA’s are charting when the
resident is dry or not, the amount of
incontinence, if the voiding was
requested or prompted
 Basic Continence Evaluation
Focused Physical Exam, including:
 Pelvic exam to assess pelvic floor & vaginal wall
relaxation and anatomic abnormalities including digital
palpation of vaginal sphincter
 Rectal exam to rule out fecal impaction & masses
including digital palpation of anal sphincter.
 Neurological exam focusing on cognition & innervation
of sacral roots 2-4 (Perineal Sensation)
 Post Void Residual to rule out urinary retention
 Mental Status exam when indicated
 Simple Urologic Tests

 Provocative Stress Testing

 Key components
 Bladder must be full
 Obtain in standing or lithotomy position
 Sudden leakage at cough, laughing,
sneezing, lifting, or other maneuvers
 Female Exam of Urethra and
Vagina
During a bed side exam the nurse should observe
for the following:
 The presence of pelvic prolapse (urethroceles,
cystoceles, rectoceles)
 It is more important that you identify the presence of a
prolapse than the particular type
 Is the vaginal wall reddened and/or thin?
 Is the vaginal wall atrophied?
 Is there abnormal discharge?
 Female Exam of Urethra and
Vagina (continued)
 Test the vaginal pH by taking small
piece of litmus paper and dabbing it in
the vaginal area
 Document the vaginal pH
 If the pH is >5 it is a positive finding
Dorsal Lithotomy Position
(Normal Vaginal Area)
 Male Exam of the Penis

 Is the foreskin abnormal? (Is the foreskin

difficult to draw back, reddened,
phimosis)
 Phimosis is a general condition in which the
foreskin of the penis can not be retracted
 Is there drainage from the penis?
 Is the glans penis urethral meatus
obstructed?
Male Genitalia
Phimosis
 Rectal Exam

 Nursing staff should perform a rectal

exam
 Document if the resident has a large
amount of stool or the presence of hard
stool
 Prostate Exam

 While completing a rectal exam for

constipation, note if you feel the
prostate enlarge
 Please note findings
The Bulbocavernous Reflex Test
 When the nurse is inserting a finger into
the anus to check for fecal impaction, the
anal sphincter should contract
 When the nurse is applying the litmus
paper to check the vaginal pH, the
vaginal muscle should contract
(When both these muscles contract this
indicates intact reflexes)
 Post Void Residual

 A post void residual should be obtained

after voiding via a straight
catheterization or via the the bladder
scan
 If the resident has > 200 cc residual the test
is positive
(Document the exact results on the
assessment form)
 Mini Mental Exam (MMSE)

 Complete a mini mental exam on the

resident
 Chart the score on the assessment form
 Score the resident on the number of
questions they answered correctly to the
total number of questions reviewed
 Basic Evaluation

 Rectocele
 Anterior and downward bulging of the
posterior vaginal wall together with the
rectum behind it
Rectocele
 Basic Evaluation

 Urethral Prolapse
 Entire circumference of urethral mucosa is
seen to protrude through meatus
Urethral Prolapse
 Basic Evaluation
 Cystocele
 Anterior wall of the vagina with the
bladder bulges into the vagina and
sometimes out of the introitus
Distension Cystocele
 Basic Evaluation

 Uterine Prolapse
 The uterus falls into the vaginal cavity
Uterine Prolapse
Huge Prolapsed Cervix
 Basic Evaluation

 Atrophic Vaginitis
 Thinning of vaginal and urethral lining
causing dryness, urgency, decreased
sensation
 Advanced
Postmenopausal Atrophy
 Treatment

Guidelines recommend least

invasive evaluation and
treatment as baseline!!
Treat Transient Causes First

Such as:
 Atrophic vaginitis
 Symptomatic urinary tract infections
(UTI)
 Hypoestrogenation Causes
(Loss of Estrogen)
 Decreased glycogen
 Decreased lactic acid
 Increased vaginal pH
 Increased risk of UTI’s
Urinary Tract Infections (UTI)

The vaginas of postmenopausal

women not being treated with
estrogen have been found to be
predominately colonized by E. coli
Circulating Estrogen Inhibits
Uropathogen Growth by:
 Colonization of the vagina with
lactobacilli
 Maintenance of acidic pH (<5)
 Positive Effects of Estrogen
Replacement
 A decrease in vaginal pH
 Reemergence of lactobacilli
 Colonization of the vagina rarely occurs
when the pH is below 4.5
Symptoms tend to re-appear
when estrogen treatment
ends!
 Other Treatments of Urinary
Incontinence
 Behavioral therapy
 Pharmacotherapy
 Electrical Stimulation
 Denervation/decentralization
 Augmentation cystoplasty
 Catheterization
 Urinary diversion
 Behavioral Treatments

 Fluid management
 Voiding frequency
 Toileting assistance
 Scheduled toileting
 Prompted voiding
 Bladder training
 Pelvic floor muscle exercise
 Bladder Training & Urgency
Inhibition Training
 Bladder Training - techniques for
postponing voiding
 Urge Inhibition Training - techniques
for resisting or inhibiting the sensation
of urgency
 Bladder training & urge inhibition training
is strongly recommended for urge &
mixed incontinence & is recommended for
management of stress incontinence
 Behavior Treatments

 Pelvic muscle exercises

 Effects of exercises
 Support, lengthen and compress the
Urethra
 Elevate the urethrovesical junction
 Increase pelvic/muscle tone
 Behavior Treatments
 Pelvic muscle (Kegel) exercises
 Goal: to improve urethral resistance and
urinary control through the active exercise
of the pubococcygenus muscle
 Components:
 Proper identification of muscle (if able to stop urine
mid-stream)
 Planned active exercise (hold for 10 seconds then
relax) 30-80 times per day for a minimum of 8 weeks
 Biofeedback

 Very helpful in assisting patients in

identifying and strengthening pelvic
muscles
 Give positive feedback for bladder training,
habit training and/or Kegels
 Pharmacotherapy

 Medications
 To relax or augment bladder or urethral
activity
 Inserts

 Pessary
 Urethral inserts
 Vaginal weights
Pessary
 Surgical Treatment
(Last Choice)

 More than 100 techniques

 Repair hypermobility
 Repair urethral support
 Contigen ™ implants (ISD)
 When do you Refer to a
Specialist?
 Uncertain diagnosis/no clear treatment
plan
 Unsuccessful therapy/resident requests
further therapy
 Surgical intervention considered/
previous surgery failed
 Hematuria without infection
 Referral to Specialist
(continued)
 Existence of other comorbid conditions:
 Recurrent symptomatic urinary tract infection
 Persistent symptoms of difficulty with bladder emptying
 Symptomatic pelvic prolapse
 Prostate nodule enlargement, asymmetry, suspicion of
cancer
 Abnormal post void residual urine
 Neurological condition: multiple sclerosis, spinal cord
lesion/injury
 History of previous radical pelvic or anti-incontinence
surgery
 Indwelling Catheters
 Indwelling catheters (urethral or suprapubic)
may be necessary for certain residents with
incontinence:
 Urinary retention that cannot be corrected medically or
surgically, cannot be managed by intermittent
catherization and is causing persistent overflow
incontinence, symptomatic UTIs
 Pressure ulcers or skin lesions that are being
contaminated by incontinent urine
 Terminally ill severely impaired residents
 Summary

With correct diagnosis of UI,

expect more than 80%
improvement or cure rate
without surgery!!
Evaluation is the Key!

Identification of the type of

urinary incontinence is the
key to effective treatment.
 Case Study 1

 Mrs. Martin:
 She was admitted to a skilled nursing
facility following a hospitalization for
surgical repair of a fractured hip which
occurred when she fell on the way to the
bathroom.
 Prior to Admission:

 She was living at home with her

daughter. Her medical history included
hypertension and osteoporosis. Mrs.
Martin’s daughter reported that her
mother frequently rushed to get to the
bathroom on time and often got out of
bed 4 to 5 times per night to urinate.
 Upon Admission to the
Nursing Home:
 A physical therapy evaluation was done
to assess Mrs. Martin’s transfer status.
The therapist recommended assistive
ambulation and the nursing staff
implemented an every 2 hour toileting
schedule. This resident’s MDS
continence coding score after 14 days
was 3 (frequently incontinent).
 Upon Admission to the
Nursing Home: (continued)
 Mrs. Martin stated that she knew when she
needed to void but could not wait until the staff
could take her to the bathroom. She could feel
the urine coming out but could not stop her
bladder from emptying. Mrs. Martin felt
embarrassed about wearing a brief but felt it
was better than getting her clothing wet. Her
incontinence was sudden, in large volumes and
accompanied by a strong sense of urgency.
 Problem Identification

 The problems identified by the staff

during the first case conference included
urge incontinence and impaired
mobility.