Incontinence in the Genital Urinary System

This session will be on the genital urinary system and fluids and electrolytes and focus on incontinence. Before you dive into this content, be sure you are free from distractions and can give it your full attention. Be sure that you have read the textbook pages that are associated with this content. Be prepared to actively learn. I will be sharing my knowledge and understanding with you, but you must do the learning. Participate in your learning. You will be the nurse next to that patient, not me. You need to acquire the knowledge, skills, and attitudes to take care of that patient safely, competently, and compassionately. Think beyond your next classroom exam. Rather, think about being that nurse taking care of that patient. That is what you are preparing for, not classroom examinations. Listen with curiosity, asking questions, seeking answers. Imagine being the nurse responsible for the care of this patient. Imagine being the patient needing this nursing care. Think about your prior experiences that are related to this content, from both the healthcare provider's point of view, and or the patient's point of view. Think about building knowledge on the foundation of what you already know. Be prepared to change your understanding of this content if new information is presented. Take advantage of this recorded source. Pause as needed to think about the content or write down notes or questions. Be curious about learning more. Review the content and your notes as needed to gain understanding that you seek. Test yourself on the content to determine if you really learned it or not. The first thing I want you to do is pause and reflect. I want you to start by stopping the recording and thinking. and writing down in these three areas. I want you to think about what you already know about this topic and write down at least three to five items. I want you to stop and think about any of your prior experiences related to the content. I want you to write down your thoughts and feelings. related to your experiences. Lastly, I want you to think about what you don't know about this content. Think about your gaps of knowledge and understanding and things that you're curious about learning. Write down at least three to five items. Then you'll be ready to dive into the content. Here are the learning objectives for this discussion. Make sure that you understand what the purpose of this is and that you'll be able to meet these objectives upon the completion. Urinary incontinence is defined as the unplanned, involuntary, or uncontrolled loss of urine from the bladder. This condition can occur for many reasons and they each have different pathophysiologies. It does affect women more often than men and affects the older population more than the younger. Some risk factors are age-related changes in the urinary tract, having a caregiver or toilet that's unavailable can lead to incontinence, having cognitive disturbances such as dementia or Parkinson's, being considered Class 3 obesity, which is extreme or severe obesity, being diabetic, having had genitourinary surgeries, to doing high impact exercises which would include the likes of running or jumping immobility having an incompetent urethra due to trauma or the sphincter being overly relaxed, certain medications including diuretics, sedatives, hypnotics, and opioids, being a menopausal female, having pelvic muscle weakness, being pregnant, so just being pregnant, or having had multiple pregnancies. Additionally, in the postpartum time, having had a vaginal delivery and or an episiotomy can increase the likelihood of being incontinent and having had a stroke. Some medications can contribute to incontinence, including high blood pressure drugs such as Cardora, Minipress, and Hytrin, some antidepressants, some diuretics. Some sleeping pills and then a variety of other medications can contribute to incontinence. Additionally, there are some food and beverage choices that can contribute to that. Alcohol, caffeine, and carbonated beverages can contribute to the development of incontinence. Incontinence can be temporary, like in the case of a patient that has a UTI that has transient. incontinence or a patient with a fecal impaction that also would just have transient incontinence and it can also be associated with Parkinson's disease. There are multiple types of urinary incontinence each with their own pathophysiology. So we'll discuss first stress incontinence which is the involuntary loss of urine through an intact urethra. as a result of exertion, sneezing, coughing, or changing positions. This can be someone who is running or even just laughing hard. Sneezing, coughing, or just changing position leads to a stress on the urethra and leakage of urine. It predominantly affects women who have had vaginal deliveries. And it is thought to be the result of descending ligament and pelvic floor support of the urethra and decreasing or absent estrogen levels within the urethra walls and the bladder base. That's obviously in the case of women. In men, stress incontinence is often experienced after a radical prostatectomy for prostate cancer because of the loss of the urethral compression. that the prostate had been supplying before surgery and maybe even bladder wall irritation. The next form of incontinence we'll talk about is urge incontinence. This is involuntary loss of urine that's associated with a strong urge to void that cannot be suppressed. It's like you suddenly have to go right now. The patient is aware of the need to void but is unable to reach the toilet in time. An uninhibited deuterosar contraction is the precipitating factor so it's like a bladder contraction and suddenly your urge is so strong you have to pee right this minute. This can occur in a patient with neurologic dysfunction that impairs the inhibition of the bladder contraction, or even in some patients that don't have overt neurological dysfunction. Sometimes the urge incontinence can be influenced by those food choices like alcohol, caffeine, carbonated beverages, and sometimes it's irritation of the bladder itself from foods that are spicy can contribute to that. There is functional Incontinence, which is due to physical or cognitive impairment. This occurs when a lower urinary tract function is intact, but other functions, such as severe cognitive impairment, make it difficult for the patient to identify the need to void, or physical impairments make it difficult for the patient to reach the toilet in time. This goes back to that list of risk factors where it talked about the lack of a caregiver. or the lack of access to the toilet, those patients would not be incontinent if they could get to the toilet in time or if their mental capacities would allow them to recognize the need to urinate before they voided in an incontinent manner. Erotogenic is involuntary loss of urine due to extrinsic medical factors, predominantly medications. One such example is the use of alpha-adrenergic agents that decrease blood pressure. In some people with an intact urinary system, these agents adversely affect the alpha receptors that are responsible for the bladder neck closing and the pressure of it. The bladder neck will then relax to the point of incontinence with minimal increase in intra-abdominal pressure. So it looks like stress incontinence but it's caused from medication and if that is the case, then discontinuing the medication will resolve the incontinence issues. Then you can have mixed incontinence, which encompasses more than one type coming together. So a patient can have stress incontinence and urge incontinence and experience incontinence under both conditions. Then there's overflow incontinence which occurs when there is continual leakage of urine from an overdistended bladder. This can occur because the deutrocer muscles under activity or an outlet obstruction caused by like BPH or a pelvic organ prolapse or even a tumor among other things. Here is an opportunity for you to pause and think about this content and apply it to your nursing care of patients with these problems. Let's just use this time to verify that you understand the differences in the types of the incontinence and understand how each one of them develops and progresses. All right, so our nursing assessment is going to begin with assessing for history of incontinence episodes. Determine if there is a pattern as this will help to identify which type this patient is experiencing and will help to guide the interventions. Assess for medications that may be contributing. Assess for any dietary influences. Assess for how the patient is currently dealing with the issue. And by that, I mean physically dealing with it, like wearing pads or incontinence undergarments. And then also... Emotionally dealing with the issue. Is it causing them stress and anxiety and trouble in their life because of the incontinence? Assess the patient's skin, especially in the perineal area to discover if there's been any skin breakdown or if there's dermatitis present that needs to be addressed. And assess their emotional status in regard to this issue. Symptom management. A patient experiencing urinary incontinence will need to manage the triggers of the events as well as the results of them. So for each type of incontinence, a different approach may be needed, but in all cases, the patient will be required a way to absorb the urine and keep their clothes and their bedding clean and dry. They will also need teaching on good skin care to protect from skin breakdown and to heal any a breakdown that has already occurred. Incontinence pads or undergarments can be very useful and allow the patient to continue their daily life even with the incontinence. Once incontinence is recognized, a thorough history is necessary. This includes a detailed description of the problem and a history of any medication use, the patient's voiding history, a diary of fluid intake and output, And sometimes bedside tests are done like a residual urine. So a patient will void and then they'll have a bladder scan to see how much is still left in there to determine if they're completely emptying their bladder or not. Sometimes there'll be a bedside test where they do a stress on the urinary tract to determine if a stress can trigger the incontinence like a Valsalva maneuver. or a cough or something like that to determine the type of incontinence that may be involved. We may also be doing urinalysis and urine cultures to identify if there's an infection that might be leading to this incontinence. Urinary incontinence can be transient, can be reversible, or it could be a lifelong struggle for the patient. If the underlying causes are successfully identified and treated, then voiding patterns usually revert back to normal. Some of the causes of transient incontinence include atropic vaginitis, urethritis, prostatitis, delirium or confusion, excessive urine production, so maybe they've had increased intake or they're diabetic and they're making excess urine, they're in ketoacidosis, these things cause excess urine production. which can make it difficult for a patient to maintain continence. They may have limited or restricted activity. You'll remember that when I gave the list of risk factors, immobility was on that list. So if we can correct that, often we can correct the incontinence. Sometimes pharmacological agents, we might have to discover if one of them is causing the problem, and then we can switch to something else that would not give the same effect. sometimes psychological factors like having depression or experiencing regression. Stool impaction or constipation and UTIs also can have an impact on transient incontinence. Medical management, in general there is no lab or imaging tests that are required for a diagnosis although sometimes Certain things are done to try to identify specific kind of incontinence. Like I mentioned, a UA if it's thought that it's because of a UTI, or it could be that we're doing that stress trigger test to see if that's what's causing, or if that's the type of incontinence that we're dealing with. Management depends on the type of incontinence and whatever's causing it. Management of the incontinence may include behavioral therapies, pharmacological, or surgical interventions. Behavioral therapies include things like pelvic floor muscle exercises, which are often referred to as Kegel. exercises. Also, just the patient keeping track of what's the triggers for it and then maybe adjusting some of their behaviors so that those triggers are removed. Or if they can't be removed, then at least the patient's aware of it and can maybe adjust their voiding schedule to meet their needs. Sometimes there is some biofeedback that's done and sometimes physical therapy. Like let's say the patient's incontinence is due to immobility. So if we can get them back to being mobile through physical therapy, then we can likely reverse their episodes of incontinence. There are pharmacological therapies that will work for certain types of. incontinence and they usually work in conjunction with behavioral interventions. Anticholinergic agents will inhibit the bladder contractions. So these are great when we're talking about urge incontinence. So when the patient has an irritable bladder and it just has spasms, that's what usually triggers the urge incontinence. So if we can give them a medication that inhibits those contractions. then they have more control over when they get to void. That allows the patient time to recognize the need to empty the bladder and time to get to the toilet. Certain beta-3 adrenergic agonists may be used for urge incontinence and overactive bladder, which can be a form of mixed incontinence, but it should not be used for patients that have hypertension because it can cause an increase in blood pressure. Some tricyclic antidepressant medications, notably amitriptyline, can be also used to decrease bladder contractions as well as increase the bladder neck resistance. And pseudofedrine sulfate can act on the alpha adrenergic receptors causing urinary retention. And so it can be used to help treat stress incontinence. But it needs to be used carefully in men that have prostatic hyperplasia or in any patient that has hypertension. Remember that any medication that is used for an off- label use, which is totally acceptable, it's still going to have the same impact on the system it was designed for. So let's say we're talking about giving an antihypertensive medication to help with urinary incontinence. It's still going to impact the patient's blood pressure. So we need to monitor for that impact in every patient. Additionally, if a patient is given an antihypertensive medication for blood pressure that may also impact the urinary tract, we must monitor for those effects as well. The body will use the drug for both purposes regardless of which reason the patient is being prescribed for it. This is why we have to know and understand every medication that the patient is taking, the indications for which he or she is taking it, and monitor for all the side effects. and the adverse effects and the therapeutic effects that come with that medication. We are now going to talk about surgical management. Sometimes patients will be given a surgical procedure to correct the incontinence if behavior or pharmacological methods are insufficient. They vary according to the underlying anatomy and the physiologic problem. Most procedures will involve lifting and stabilizing the bladder or the urethra to restore normal urovesicular angle or to lengthen the urethra. Women with stress incontinence can go anterior vaginal repair, retropubic suspension, or needle suspension to reposition the urethra. So just changing the, it's like over time the bladder and the urethra shift a little, especially in women that have had multiple pregnancies or had any kind of trauma to that part of the body. And so if we can raise up the bladder and or the urethra, sometimes that will change the pressure gradient. and allow the patient to have relief of that stress incontinence. And occasionally one of the procedures that's done is called periurethral bulking. It's very minimally invasive procedure where small amounts of artificial collagen are placed within the walls of the urethra. that enhances the closing pressure of the urethra. So it makes that sphincter a little stronger, a little more responsive to the patient deciding whether to open or close that sphincter. The procedure can take 10 to 20 minutes and it's performed on their local anesthetic or moderate sedation. Now the drawback of this procedure is that eventually the body will absorb that collagen that's been placed in there and so it may be that the patient needs a repeat procedure somewhere down the line. Some other interventions can include fluid management. Now patients should be encouraged to continue a normal fluid intake but sometimes sometimes they may benefit from changing the timing of when they drink. It may benefit them to decrease fluid intake prior to an appointment or an event that will help decrease the incontinence during those times, or to decrease fluid intake before they go and exercise if stress incontinence is one of their issues. Additionally, they may benefit from reducing alcohol, caffeine, artificial sweeteners, and carbonated drinks. these can irritate the bladder and lead to urinary urgency. They can follow a standardized voiding schedule. So that can be done by helping the patient to remember to go and void on a certain schedule, perhaps every two hours. And this is good for patients that have cognitive impairment and they can't necessarily connect the fact that they recognize they need to urinate and then get to the toilet. So the object is to purposely empty the bladder before it reaches that critical volume that would cause urge or stress incontinence. So we do timed voiding where the patient just automatically voids by the clock or if they can't take themselves to the commode then a caregiver. helps them to void every two hours or however often is determined is the right interval for that patient. Habit retraining is timing voiding at an interval that is more frequent than they're usually done. This technique helps to restore the sensation to need to void in individuals who are experiencing a diminished sensation. like they can't quite tell if their bladder is full or not, like in patients that have had a stroke. Bladder retraining, also known as bladder drill, incorporates a timed voiding schedule and urinary urge inhibition exercises to inhibit voiding or leaking of urine in an attempt to remain dry for a set amount of time. When the first timing interval is easily reached on a consistent basis without urinary urgency or incontinence, then a new voiding interval is set. So maybe they stretch the time then from one hour to an hour and 15 minutes. And then they practice at that time interval. And then they stretch it again. Whenever an accepting voiding interval is reached, the patient continues at that timing sequence throughout their day. I mentioned previously pelvic muscle exercises, also known as Kegel exercises. These aim to strengthen the voluntary muscles that assist in bladder and bowel continence, and they happen in both men and women. We can have a system where there's biofeedback. that is given. So either electromyograph or manometry are used to help the individual identify which muscles that they're actually trying to contract when they're performing these, because it can be really difficult when it's an area of your body that you're not used to consciously thinking about contracting. So the biofeedback method kind of helps the patient identify. the area. And then the pelvic muscle exercise just means that they're tightening those muscles, the same exact muscles that they'd use if they were trying to stop themselves from passing gas or trying to stop the flow of urine. This can be an effective way to strengthen these muscles and decrease incontinence. It needs to be done consistently. about two to three times a day for at least six weeks to develop these muscles and this ability to retain the urine rather than be incontinent. Older patients may need to exercise for an even longer period of time to strengthen the pelvic floor muscles because everything gets a little weaker as we get older. Pelvic muscle exercises are helpful for women that have stress, urge, or mixed incontinence, and for men who have undergone prostate surgery and then have developed incontinence from that. One good aspect of this practice is these exercises can be done anywhere at any time. And once you identify the correct muscles, there is no equipment needed. So a patient can complete these exercises every time they void and at intervals throughout the day. Like if they're sitting around and watching television, they can say do 10 or 20 repetitions every time the commercial comes on. Or if they're driving from point A to point B, they can determine that every time they're sitting on a stoplight, they can do 10 or 20 repetitions of these pelvic floor exercises. but they need to be encouraged to develop a routine that can easily fit into their lifestyle and be consistent. Another intervention can be vaginal cone retention exercises. So this is an instance where a weighted cone is placed within the vagina and then the patient has to contract the muscles in that area to retain that cone against gravity. So they would do that for maybe trying to retain it for a few minutes up to maybe even 15 minutes and then we would obviously need to start with a low weight cone and gradually increase in size, weight of it until the patient has developed more control of those muscles. There is transvaginal or transrectal electrical stimulation that can be done. It is a way to elicit a passive contraction of the pelvic floor muscles. So it's like an electrical stimulation that causes those muscles to automatically contract. It is often used with biofeedback so that a patient can feel the contraction and then practice those muscle training activities and incorporate that into their voiding schedule. At high frequencies, it is useful for stress incontinence. At low frequency, it can also relieve symptoms of urinary urgency, frequency, and urge incontinence. And then intermediate ranges are used for mixed incontinence. We can have artificial sphincters that are used to help close the urethra and promote incontinence. Two types. are the periurethral cuff and a cuff inflation pump. Those, I'm not sure how prevalent the use is. I haven't seen them myself in practice. Now, nursing management. The nurse may encounter a patient with incontinence either in the hospital or as an outpatient. The management of the patient with incontinence in any setting is based on the premise that incontinence is not inevitable with aging or illness and that is often reversible and treatable. Assessment of the Brayden scale will help to identify risks that patients have and guide the nurse in appropriate interventions based on the patient's individual concerns. Patients who are incontinent and hospital need routine skin assessment to distinguish between incontinence associated dermatitis and pressure injuries. When either of these are identified, then appropriate management techniques must be implemented to avoid complications. Incontinence will always require interventions, but that will often not include catheterization. Indications for appropriate indwelling catheterization can include incontinence when there is a wound that would be impacted by the moisture that's associated with the incontinence. Make sure that you review and understand the appropriate indications for the use of an indwelling catheter and the need to assess the patient's status to determine if a catheter is needed and to reassess its continued use every 12 hours. Additionally, we want to monitor for the skin breakdown. Also falls. Falls are at, patients who have incontinence are at higher risk of falls. And this is due, one, maybe to slipping because of the wet floor, or it could be due to just trying to hurry to get to the toilet or hurry to remove. their clothing in time to avoid in the commode instead of on their clothes. So increased immobility and decreased daily activities contribute to incontinence as well. For this pause and think, I would like you to create a plan of interventions for this patient. She's an 83 year old female and she has the following comorbidities. She has stress incontinence and overflow incontinence. as well as hypertension for which she takes 5 milligrams of Carvedilol every day, and she also has congestive heart failure and she has a fluid restriction of 1000 milliliters per day. Alright, to begin with our educational considerations. Remember that incontinence is not inevitable and it's not necessary. The causes can be identified. Interventions can be implemented to improve, reduce, or even eliminate incontinence from many patients. Although the bladder of the older person is more vulnerable to altered deuterosar activity, age alone is not a risk factor for urinary incontinence. The patient will need education on the type of incontinence and the appropriate associated interventions. Teaching about pelvic floor muscle exercises can benefit most patients. patients with incontinence. If medications are prescribed, the nurse will need to provide a thorough education on all aspects for each medication, including how the new medications will interact with the other medications that the patient may currently be taking. The nurse should also educate on incontinence products as appropriate. Nursing interventions in the outpatient setting are determined in part by the type of treatment that is undertaken. For behavioral therapy to be effective, the nurse must provide support and encouragement because it is easy for the patient to become discouraged and think that it's never going to work because it can take a while for these interventions to show results. Patient education is important and should be provided both verbally and in writing. Especially geared towards your patient's preferred method of learning. The patient should be encouraged to develop and use a log or a diary to record the timing of their pelvic floor muscle exercises, how frequently they're voiding, their episodes of incontinence, and if they notice any changes in their bladder function. Because these can encourage the patient to continue the practice. The nurse can instruct the patient to avoid bladder irritants like caffeine, alcohol, artificial sweeteners, and sometimes spicy foods and carbonated beverages. The patient should, and this is just in general, any patient that's taking a diuretic ought to avoid taking them after four o'clock in the afternoon because then the medication effect can carry over into after the patient's gone to bed and cause the patient to either have increased episodes of incontinence during the night or need to get up to urinate excessively during the night, which can lead to increased risk of falls. The patient should also be taught to have an increased awareness of the amount and the timing of their fluid intake, performing pelvic floor exercises. This would be another great reason for a patient to stop smoking. Smokers that have frequent coughing can increase the risk of stress incontinence. So stopping smoking can help a patient in those in those situations. Because fecal impaction or constipation can actually contribute to incontinence, We'd like to help the patient to avoid constipation. Drinking adequate fluids, eating a balanced diet, exercising regularly, and maybe even taking a stool softener if that's required. Voiding regularly five to eight times a day about every two to three hours. So we want them voiding maybe first thing in the morning. Almost everybody will urinate immediately getting out of bed. before they go sit down for a meal, before they go to bed, and then maybe even during the night if necessary. If surgical corrections are undertaken, then the procedure and its desired outcome need to be described to the patient and their family. They need to understand what their follow-up care is going to need to be. And then the nurse needs to be able to answer all their questions and reinforce and encourage as a person. Now, in the psychosocial aspect, Urinary incontinence can decrease anybody's ability to maintain an independent lifestyle, but this happens frequently with older persons, which increases their dependence on caregivers and may lead to the patient having to be institutionalized and maybe living in a care facility. It is said that between 35 and 41 percent of older women have urinary incontinence. This can also lead to social isolation and depression or anxiety. Being incontinent of bowel or bladder is embarrassing to most adults and should be discussed with respect with the patient. So we want to treat this subject respectfully and with care for the patient's emotions and their response and perhaps embarrassment. Ensure the patient that this condition in no way lessens them as a person. And even if we have to go in and change the bed and get them clean and dry multiple times during the shift, it is our job to do that. That's one of the things we're signing up for when we become the nurse. And we should not make the patient feel in any way guilty or embarrassed for needing our help and for us doing our job. the one that we signed up for. We want to help them manage their concerns with dealing with social activities, with mobility, and with their ADLs. Ensure that the patient has either the ability to keep themselves clean and dry or assistance that they need in order to keep themselves clean and dry so we can prevent skin breakdown and dermatitis. They need to be able to change their clothes if necessary, and if they can't, then we need to link them with resources as needed for these areas of concern. We need to help the patient to develop a plan and a strategy because they need to be their own advocate and their own lead partner in taking care of this problem. So if they think that they can do the pelvic floor muscle exercises, then we uphold their determination to do that. If they are struggling to give up their caffeine and they really think that's going to be one of the factors that helps them get better, then we need to support them as they strive to make that change. But they are in charge of their own plan and their strategy. The patient can always agree or disagree with every single intervention that we offer them and they have the right to accept or refuse any of our treatments. So for this pause and think, I want you to create a list of talking points that you would use to discuss incontinence with a patient. How would you begin the discussion and what areas do you think are the most important to talk about? How would you handle this discussion while treating the patient with value and respect? This is the end of the content. Be sure to review these learning objectives. Test yourself on this information. If you still have gaps in your knowledge, review this presentation, dig into your textbook, watch videos, and or seek tutoring until you are sure of your knowledge. and understanding of this content. Thank you.

I will be sharing my knowledge and understanding with you, but you must do the learning. Participate in your learning. You will be the nurse next to that patient, not me.

You need to acquire the knowledge, skills, and attitudes to take care of that patient safely, competently, and compassionately. Think beyond your next classroom exam. Rather, think about being that nurse taking care of that patient. That is what you are preparing for, not classroom examinations.

Listen with curiosity, asking questions, seeking answers. Imagine being the nurse responsible for the care of this patient. Imagine being the patient needing this nursing care. Think about your prior experiences that are related to this content, from both the healthcare provider's point of view, and or the patient's point of view.

Think about building knowledge on the foundation of what you already know. Be prepared to change your understanding of this content if new information is presented. Take advantage of this recorded source. Pause as needed to think about the content or write down notes or questions.

Be curious about learning more. Review the content and your notes as needed to gain understanding that you seek. Test yourself on the content to determine if you really learned it or not.

The first thing I want you to do is pause and reflect. I want you to start by stopping the recording and thinking. and writing down in these three areas.

I want you to think about what you already know about this topic and write down at least three to five items. I want you to stop and think about any of your prior experiences related to the content. I want you to write down your thoughts and feelings.

related to your experiences. Lastly, I want you to think about what you don't know about this content. Think about your gaps of knowledge and understanding and things that you're curious about learning. Write down at least three to five items.

Then you'll be ready to dive into the content. Here are the learning objectives for this discussion. Make sure that you understand what the purpose of this is and that you'll be able to meet these objectives upon the completion. Urinary incontinence is defined as the unplanned, involuntary, or uncontrolled loss of urine from the bladder. This condition can occur for many reasons and they each have different pathophysiologies.

It does affect women more often than men and affects the older population more than the younger. Some risk factors are age-related changes in the urinary tract, having a caregiver or toilet that's unavailable can lead to incontinence, having cognitive disturbances such as dementia or Parkinson's, being considered Class 3 obesity, which is extreme or severe obesity, being diabetic, having had genitourinary surgeries, to doing high impact exercises which would include the likes of running or jumping immobility having an incompetent urethra due to trauma or the sphincter being overly relaxed, certain medications including diuretics, sedatives, hypnotics, and opioids, being a menopausal female, having pelvic muscle weakness, being pregnant, so just being pregnant, or having had multiple pregnancies. Additionally, in the postpartum time, having had a vaginal delivery and or an episiotomy can increase the likelihood of being incontinent and having had a stroke. Some medications can contribute to incontinence, including high blood pressure drugs such as Cardora, Minipress, and Hytrin, some antidepressants, some diuretics. Some sleeping pills and then a variety of other medications can contribute to incontinence.

Additionally, there are some food and beverage choices that can contribute to that. Alcohol, caffeine, and carbonated beverages can contribute to the development of incontinence. Incontinence can be temporary, like in the case of a patient that has a UTI that has transient.

incontinence or a patient with a fecal impaction that also would just have transient incontinence and it can also be associated with Parkinson's disease. There are multiple types of urinary incontinence each with their own pathophysiology. So we'll discuss first stress incontinence which is the involuntary loss of urine through an intact urethra. as a result of exertion, sneezing, coughing, or changing positions. This can be someone who is running or even just laughing hard.

Sneezing, coughing, or just changing position leads to a stress on the urethra and leakage of urine. It predominantly affects women who have had vaginal deliveries. And it is thought to be the result of descending ligament and pelvic floor support of the urethra and decreasing or absent estrogen levels within the urethra walls and the bladder base.

That's obviously in the case of women. In men, stress incontinence is often experienced after a radical prostatectomy for prostate cancer because of the loss of the urethral compression. that the prostate had been supplying before surgery and maybe even bladder wall irritation.

The next form of incontinence we'll talk about is urge incontinence. This is involuntary loss of urine that's associated with a strong urge to void that cannot be suppressed. It's like you suddenly have to go right now. The patient is aware of the need to void but is unable to reach the toilet in time. An uninhibited deuterosar contraction is the precipitating factor so it's like a bladder contraction and suddenly your urge is so strong you have to pee right this minute.

This can occur in a patient with neurologic dysfunction that impairs the inhibition of the bladder contraction, or even in some patients that don't have overt neurological dysfunction. Sometimes the urge incontinence can be influenced by those food choices like alcohol, caffeine, carbonated beverages, and sometimes it's irritation of the bladder itself from foods that are spicy can contribute to that. There is functional Incontinence, which is due to physical or cognitive impairment. This occurs when a lower urinary tract function is intact, but other functions, such as severe cognitive impairment, make it difficult for the patient to identify the need to void, or physical impairments make it difficult for the patient to reach the toilet in time. This goes back to that list of risk factors where it talked about the lack of a caregiver.

or the lack of access to the toilet, those patients would not be incontinent if they could get to the toilet in time or if their mental capacities would allow them to recognize the need to urinate before they voided in an incontinent manner. Erotogenic is involuntary loss of urine due to extrinsic medical factors, predominantly medications. One such example is the use of alpha-adrenergic agents that decrease blood pressure.

In some people with an intact urinary system, these agents adversely affect the alpha receptors that are responsible for the bladder neck closing and the pressure of it. The bladder neck will then relax to the point of incontinence with minimal increase in intra-abdominal pressure. So it looks like stress incontinence but it's caused from medication and if that is the case, then discontinuing the medication will resolve the incontinence issues. Then you can have mixed incontinence, which encompasses more than one type coming together.

So a patient can have stress incontinence and urge incontinence and experience incontinence under both conditions. Then there's overflow incontinence which occurs when there is continual leakage of urine from an overdistended bladder. This can occur because the deutrocer muscles under activity or an outlet obstruction caused by like BPH or a pelvic organ prolapse or even a tumor among other things.

Here is an opportunity for you to pause and think about this content and apply it to your nursing care of patients with these problems. Let's just use this time to verify that you understand the differences in the types of the incontinence and understand how each one of them develops and progresses. All right, so our nursing assessment is going to begin with assessing for history of incontinence episodes. Determine if there is a pattern as this will help to identify which type this patient is experiencing and will help to guide the interventions. Assess for medications that may be contributing.

Assess for any dietary influences. Assess for how the patient is currently dealing with the issue. And by that, I mean physically dealing with it, like wearing pads or incontinence undergarments.

And then also... Emotionally dealing with the issue. Is it causing them stress and anxiety and trouble in their life because of the incontinence? Assess the patient's skin, especially in the perineal area to discover if there's been any skin breakdown or if there's dermatitis present that needs to be addressed. And assess their emotional status in regard to this issue.

Symptom management. A patient experiencing urinary incontinence will need to manage the triggers of the events as well as the results of them. So for each type of incontinence, a different approach may be needed, but in all cases, the patient will be required a way to absorb the urine and keep their clothes and their bedding clean and dry.

They will also need teaching on good skin care to protect from skin breakdown and to heal any a breakdown that has already occurred. Incontinence pads or undergarments can be very useful and allow the patient to continue their daily life even with the incontinence. Once incontinence is recognized, a thorough history is necessary. This includes a detailed description of the problem and a history of any medication use, the patient's voiding history, a diary of fluid intake and output, And sometimes bedside tests are done like a residual urine.

So a patient will void and then they'll have a bladder scan to see how much is still left in there to determine if they're completely emptying their bladder or not. Sometimes there'll be a bedside test where they do a stress on the urinary tract to determine if a stress can trigger the incontinence like a Valsalva maneuver. or a cough or something like that to determine the type of incontinence that may be involved.

We may also be doing urinalysis and urine cultures to identify if there's an infection that might be leading to this incontinence. Urinary incontinence can be transient, can be reversible, or it could be a lifelong struggle for the patient. If the underlying causes are successfully identified and treated, then voiding patterns usually revert back to normal. Some of the causes of transient incontinence include atropic vaginitis, urethritis, prostatitis, delirium or confusion, excessive urine production, so maybe they've had increased intake or they're diabetic and they're making excess urine, they're in ketoacidosis, these things cause excess urine production. which can make it difficult for a patient to maintain continence.

They may have limited or restricted activity. You'll remember that when I gave the list of risk factors, immobility was on that list. So if we can correct that, often we can correct the incontinence. Sometimes pharmacological agents, we might have to discover if one of them is causing the problem, and then we can switch to something else that would not give the same effect.

sometimes psychological factors like having depression or experiencing regression. Stool impaction or constipation and UTIs also can have an impact on transient incontinence. Medical management, in general there is no lab or imaging tests that are required for a diagnosis although sometimes Certain things are done to try to identify specific kind of incontinence.

Like I mentioned, a UA if it's thought that it's because of a UTI, or it could be that we're doing that stress trigger test to see if that's what's causing, or if that's the type of incontinence that we're dealing with. Management depends on the type of incontinence and whatever's causing it. Management of the incontinence may include behavioral therapies, pharmacological, or surgical interventions. Behavioral therapies include things like pelvic floor muscle exercises, which are often referred to as Kegel.

exercises. Also, just the patient keeping track of what's the triggers for it and then maybe adjusting some of their behaviors so that those triggers are removed. Or if they can't be removed, then at least the patient's aware of it and can maybe adjust their voiding schedule to meet their needs. Sometimes there is some biofeedback that's done and sometimes physical therapy. Like let's say the patient's incontinence is due to immobility.

So if we can get them back to being mobile through physical therapy, then we can likely reverse their episodes of incontinence. There are pharmacological therapies that will work for certain types of. incontinence and they usually work in conjunction with behavioral interventions. Anticholinergic agents will inhibit the bladder contractions.

So these are great when we're talking about urge incontinence. So when the patient has an irritable bladder and it just has spasms, that's what usually triggers the urge incontinence. So if we can give them a medication that inhibits those contractions.

then they have more control over when they get to void. That allows the patient time to recognize the need to empty the bladder and time to get to the toilet. Certain beta-3 adrenergic agonists may be used for urge incontinence and overactive bladder, which can be a form of mixed incontinence, but it should not be used for patients that have hypertension because it can cause an increase in blood pressure.

Some tricyclic antidepressant medications, notably amitriptyline, can be also used to decrease bladder contractions as well as increase the bladder neck resistance. And pseudofedrine sulfate can act on the alpha adrenergic receptors causing urinary retention. And so it can be used to help treat stress incontinence. But it needs to be used carefully in men that have prostatic hyperplasia or in any patient that has hypertension. Remember that any medication that is used for an off- label use, which is totally acceptable, it's still going to have the same impact on the system it was designed for.

So let's say we're talking about giving an antihypertensive medication to help with urinary incontinence. It's still going to impact the patient's blood pressure. So we need to monitor for that impact in every patient.

Additionally, if a patient is given an antihypertensive medication for blood pressure that may also impact the urinary tract, we must monitor for those effects as well. The body will use the drug for both purposes regardless of which reason the patient is being prescribed for it. This is why we have to know and understand every medication that the patient is taking, the indications for which he or she is taking it, and monitor for all the side effects. and the adverse effects and the therapeutic effects that come with that medication.

We are now going to talk about surgical management. Sometimes patients will be given a surgical procedure to correct the incontinence if behavior or pharmacological methods are insufficient. They vary according to the underlying anatomy and the physiologic problem.

Most procedures will involve lifting and stabilizing the bladder or the urethra to restore normal urovesicular angle or to lengthen the urethra. Women with stress incontinence can go anterior vaginal repair, retropubic suspension, or needle suspension to reposition the urethra. So just changing the, it's like over time the bladder and the urethra shift a little, especially in women that have had multiple pregnancies or had any kind of trauma to that part of the body. And so if we can raise up the bladder and or the urethra, sometimes that will change the pressure gradient. and allow the patient to have relief of that stress incontinence.

And occasionally one of the procedures that's done is called periurethral bulking. It's very minimally invasive procedure where small amounts of artificial collagen are placed within the walls of the urethra. that enhances the closing pressure of the urethra. So it makes that sphincter a little stronger, a little more responsive to the patient deciding whether to open or close that sphincter. The procedure can take 10 to 20 minutes and it's performed on their local anesthetic or moderate sedation.

Now the drawback of this procedure is that eventually the body will absorb that collagen that's been placed in there and so it may be that the patient needs a repeat procedure somewhere down the line. Some other interventions can include fluid management. Now patients should be encouraged to continue a normal fluid intake but sometimes sometimes they may benefit from changing the timing of when they drink.

It may benefit them to decrease fluid intake prior to an appointment or an event that will help decrease the incontinence during those times, or to decrease fluid intake before they go and exercise if stress incontinence is one of their issues. Additionally, they may benefit from reducing alcohol, caffeine, artificial sweeteners, and carbonated drinks. these can irritate the bladder and lead to urinary urgency.

They can follow a standardized voiding schedule. So that can be done by helping the patient to remember to go and void on a certain schedule, perhaps every two hours. And this is good for patients that have cognitive impairment and they can't necessarily connect the fact that they recognize they need to urinate and then get to the toilet. So the object is to purposely empty the bladder before it reaches that critical volume that would cause urge or stress incontinence. So we do timed voiding where the patient just automatically voids by the clock or if they can't take themselves to the commode then a caregiver.

helps them to void every two hours or however often is determined is the right interval for that patient. Habit retraining is timing voiding at an interval that is more frequent than they're usually done. This technique helps to restore the sensation to need to void in individuals who are experiencing a diminished sensation. like they can't quite tell if their bladder is full or not, like in patients that have had a stroke.

Bladder retraining, also known as bladder drill, incorporates a timed voiding schedule and urinary urge inhibition exercises to inhibit voiding or leaking of urine in an attempt to remain dry for a set amount of time. When the first timing interval is easily reached on a consistent basis without urinary urgency or incontinence, then a new voiding interval is set. So maybe they stretch the time then from one hour to an hour and 15 minutes. And then they practice at that time interval. And then they stretch it again.

Whenever an accepting voiding interval is reached, the patient continues at that timing sequence throughout their day. I mentioned previously pelvic muscle exercises, also known as Kegel exercises. These aim to strengthen the voluntary muscles that assist in bladder and bowel continence, and they happen in both men and women. We can have a system where there's biofeedback.

that is given. So either electromyograph or manometry are used to help the individual identify which muscles that they're actually trying to contract when they're performing these, because it can be really difficult when it's an area of your body that you're not used to consciously thinking about contracting. So the biofeedback method kind of helps the patient identify.

the area. And then the pelvic muscle exercise just means that they're tightening those muscles, the same exact muscles that they'd use if they were trying to stop themselves from passing gas or trying to stop the flow of urine. This can be an effective way to strengthen these muscles and decrease incontinence. It needs to be done consistently. about two to three times a day for at least six weeks to develop these muscles and this ability to retain the urine rather than be incontinent.

Older patients may need to exercise for an even longer period of time to strengthen the pelvic floor muscles because everything gets a little weaker as we get older. Pelvic muscle exercises are helpful for women that have stress, urge, or mixed incontinence, and for men who have undergone prostate surgery and then have developed incontinence from that. One good aspect of this practice is these exercises can be done anywhere at any time. And once you identify the correct muscles, there is no equipment needed. So a patient can complete these exercises every time they void and at intervals throughout the day.

Like if they're sitting around and watching television, they can say do 10 or 20 repetitions every time the commercial comes on. Or if they're driving from point A to point B, they can determine that every time they're sitting on a stoplight, they can do 10 or 20 repetitions of these pelvic floor exercises. but they need to be encouraged to develop a routine that can easily fit into their lifestyle and be consistent. Another intervention can be vaginal cone retention exercises.

So this is an instance where a weighted cone is placed within the vagina and then the patient has to contract the muscles in that area to retain that cone against gravity. So they would do that for maybe trying to retain it for a few minutes up to maybe even 15 minutes and then we would obviously need to start with a low weight cone and gradually increase in size, weight of it until the patient has developed more control of those muscles. There is transvaginal or transrectal electrical stimulation that can be done. It is a way to elicit a passive contraction of the pelvic floor muscles. So it's like an electrical stimulation that causes those muscles to automatically contract.

It is often used with biofeedback so that a patient can feel the contraction and then practice those muscle training activities and incorporate that into their voiding schedule. At high frequencies, it is useful for stress incontinence. At low frequency, it can also relieve symptoms of urinary urgency, frequency, and urge incontinence. And then intermediate ranges are used for mixed incontinence.

We can have artificial sphincters that are used to help close the urethra and promote incontinence. Two types. are the periurethral cuff and a cuff inflation pump.

Those, I'm not sure how prevalent the use is. I haven't seen them myself in practice. Now, nursing management. The nurse may encounter a patient with incontinence either in the hospital or as an outpatient.

The management of the patient with incontinence in any setting is based on the premise that incontinence is not inevitable with aging or illness and that is often reversible and treatable. Assessment of the Brayden scale will help to identify risks that patients have and guide the nurse in appropriate interventions based on the patient's individual concerns. Patients who are incontinent and hospital need routine skin assessment to distinguish between incontinence associated dermatitis and pressure injuries.

When either of these are identified, then appropriate management techniques must be implemented to avoid complications. Incontinence will always require interventions, but that will often not include catheterization. Indications for appropriate indwelling catheterization can include incontinence when there is a wound that would be impacted by the moisture that's associated with the incontinence.

Make sure that you review and understand the appropriate indications for the use of an indwelling catheter and the need to assess the patient's status to determine if a catheter is needed and to reassess its continued use every 12 hours. Additionally, we want to monitor for the skin breakdown. Also falls.

Falls are at, patients who have incontinence are at higher risk of falls. And this is due, one, maybe to slipping because of the wet floor, or it could be due to just trying to hurry to get to the toilet or hurry to remove. their clothing in time to avoid in the commode instead of on their clothes.

So increased immobility and decreased daily activities contribute to incontinence as well. For this pause and think, I would like you to create a plan of interventions for this patient. She's an 83 year old female and she has the following comorbidities.

She has stress incontinence and overflow incontinence. as well as hypertension for which she takes 5 milligrams of Carvedilol every day, and she also has congestive heart failure and she has a fluid restriction of 1000 milliliters per day. Alright, to begin with our educational considerations. Remember that incontinence is not inevitable and it's not necessary.

The causes can be identified. Interventions can be implemented to improve, reduce, or even eliminate incontinence from many patients. Although the bladder of the older person is more vulnerable to altered deuterosar activity, age alone is not a risk factor for urinary incontinence. The patient will need education on the type of incontinence and the appropriate associated interventions. Teaching about pelvic floor muscle exercises can benefit most patients.

patients with incontinence. If medications are prescribed, the nurse will need to provide a thorough education on all aspects for each medication, including how the new medications will interact with the other medications that the patient may currently be taking. The nurse should also educate on incontinence products as appropriate.

Nursing interventions in the outpatient setting are determined in part by the type of treatment that is undertaken. For behavioral therapy to be effective, the nurse must provide support and encouragement because it is easy for the patient to become discouraged and think that it's never going to work because it can take a while for these interventions to show results. Patient education is important and should be provided both verbally and in writing.

Especially geared towards your patient's preferred method of learning. The patient should be encouraged to develop and use a log or a diary to record the timing of their pelvic floor muscle exercises, how frequently they're voiding, their episodes of incontinence, and if they notice any changes in their bladder function. Because these can encourage the patient to continue the practice.

The nurse can instruct the patient to avoid bladder irritants like caffeine, alcohol, artificial sweeteners, and sometimes spicy foods and carbonated beverages. The patient should, and this is just in general, any patient that's taking a diuretic ought to avoid taking them after four o'clock in the afternoon because then the medication effect can carry over into after the patient's gone to bed and cause the patient to either have increased episodes of incontinence during the night or need to get up to urinate excessively during the night, which can lead to increased risk of falls. The patient should also be taught to have an increased awareness of the amount and the timing of their fluid intake, performing pelvic floor exercises.

This would be another great reason for a patient to stop smoking. Smokers that have frequent coughing can increase the risk of stress incontinence. So stopping smoking can help a patient in those in those situations.

Because fecal impaction or constipation can actually contribute to incontinence, We'd like to help the patient to avoid constipation. Drinking adequate fluids, eating a balanced diet, exercising regularly, and maybe even taking a stool softener if that's required. Voiding regularly five to eight times a day about every two to three hours. So we want them voiding maybe first thing in the morning.

Almost everybody will urinate immediately getting out of bed. before they go sit down for a meal, before they go to bed, and then maybe even during the night if necessary. If surgical corrections are undertaken, then the procedure and its desired outcome need to be described to the patient and their family. They need to understand what their follow-up care is going to need to be.

And then the nurse needs to be able to answer all their questions and reinforce and encourage as a person. Now, in the psychosocial aspect, Urinary incontinence can decrease anybody's ability to maintain an independent lifestyle, but this happens frequently with older persons, which increases their dependence on caregivers and may lead to the patient having to be institutionalized and maybe living in a care facility. It is said that between 35 and 41 percent of older women have urinary incontinence. This can also lead to social isolation and depression or anxiety. Being incontinent of bowel or bladder is embarrassing to most adults and should be discussed with respect with the patient.

So we want to treat this subject respectfully and with care for the patient's emotions and their response and perhaps embarrassment. Ensure the patient that this condition in no way lessens them as a person. And even if we have to go in and change the bed and get them clean and dry multiple times during the shift, it is our job to do that.

That's one of the things we're signing up for when we become the nurse. And we should not make the patient feel in any way guilty or embarrassed for needing our help and for us doing our job. the one that we signed up for.

We want to help them manage their concerns with dealing with social activities, with mobility, and with their ADLs. Ensure that the patient has either the ability to keep themselves clean and dry or assistance that they need in order to keep themselves clean and dry so we can prevent skin breakdown and dermatitis. They need to be able to change their clothes if necessary, and if they can't, then we need to link them with resources as needed for these areas of concern. We need to help the patient to develop a plan and a strategy because they need to be their own advocate and their own lead partner in taking care of this problem. So if they think that they can do the pelvic floor muscle exercises, then we uphold their determination to do that.

If they are struggling to give up their caffeine and they really think that's going to be one of the factors that helps them get better, then we need to support them as they strive to make that change. But they are in charge of their own plan and their strategy. The patient can always agree or disagree with every single intervention that we offer them and they have the right to accept or refuse any of our treatments.

So for this pause and think, I want you to create a list of talking points that you would use to discuss incontinence with a patient. How would you begin the discussion and what areas do you think are the most important to talk about? How would you handle this discussion while treating the patient with value and respect? This is the end of the content. Be sure to review these learning objectives.

Test yourself on this information. If you still have gaps in your knowledge, review this presentation, dig into your textbook, watch videos, and or seek tutoring until you are sure of your knowledge. and understanding of this content.

Thank you.

Transcript for:Incontinence in the Genital Urinary System

Transcript for:
Incontinence in the Genital Urinary System