Urinary Incontinence

Urinary incontinence is defined as an involuntary loss of urine that is severe enough to cause social or physical consequences for the individual experiencing it. Urinary incontinence affects 35% of all adults and 50% of those residing in long-term care facilities. In fact, it is a leading cause of admission to long-term care facilities. Costs related to urinary incontinence complications are $2.8 billion per year, making it a major health concern for healthcare providers and patients alike. Among chronic conditions in the United States, urinary incontinence ranks as the 4th most common, yet it is often under diagnosed and underreported.

Loss of bowel or bladder control is not an ordinary part of the normal aging process, and treatable causes should be investigated. Incontinence can lead to feelings of shame and embarrassment for the resident, and is a risk factor for rashes, pressure ulcers, and urinary tract infections. There is an increased risk of falls resulting in fracture in those trying to reach a toilet before becoming incontinent.

The effects of treatment for urinary incontinence can be great on improving an individual’s quality of life. In fact, up to 80% of those who experience incontinence can be cured or have improvement of their symptoms with appropriate treatment. It is important to understand the type of urinary incontinence your loved one is experiencing so you can encourage appropriate treatments and decrease the risk of accidents and injuries related to incontinence.

What are some risk factors for urinary incontinence?

Risk factors for urinary incontinence include advanced age, prior pelvic surgery, obesity, declining estrogen levels, chronic medical conditions, diabetes, restricted mobility, the use of physical restraints, constipation, smoking, swelling in the legs, psychiatric disorders, urinary tract infections, restriction of fluids, taking in excess fluids, medication side effects from diuretics, blood pressure medications, pain medications, sleeping pills, cold remedies, and antidepressants, which may include increased loss of urine, sedation, and confusion.

What are the types of urinary incontinence?

It is important that the nursing home and your loved one’s physician define the type of urinary incontinence because treatment will differ based on the type present.

  • Stress incontinence occurs due to increased abdominal pressure, such as when the person coughs, sneezes, laughs, or exercises. Only small amounts of urine are lost and loss is often predictable. It happens mostly in women due to the effects of childbirth and is worse in those who are overweight.
  • Urge Incontinence (Over-Active Bladder – OAB) is defined as involuntary urine loss that occurs due to bladder over activity. It occurs without warning and often cannot be prevented. The entire contents of the bladder are lost at once. Symptoms include urinary frequency, urgency, and loss of large amounts of urine during the night. Activities such as turning a key in the door, washing dishes, or hearing running water can cause incontinence. Some people may have the symptoms of both stress and urge incontinence. Urge incontinence is the most common type of incontinence experienced in elders.
  • Overflow incontinence occurs due to an over distended bladder. Common causes are prostate enlargement, bladder neck contracture, urethral strictures, stones, tumors, herniated lumber disc, and nerve damage from diabetes.
  • Functional incontinence is caused by impaired mobility or communication that prevents patients from reaching a toilet before urine loss occurs. Treatment includes simply being attentive to the resident’s needs.

How is urinary incontinence treated?

Sometimes simple things such as changes in diet, fluid intake, or medication can cure incontinence. Sometimes other types of treatments are needed, including the following:

  • Pelvic floor muscle (Kegel) exercises are designed to strengthen or retrain pelvic floor muscles and sphincter muscles to reduce or cure leakage. They are effective for stress and urge incontinence. These exercises can be taught by therapy staff or restorative nursing in the nursing home.
  • Timed voiding is a common way to treat incontinence in the nursing home setting. It involves charting voiding and leaking for a certain number of days. From this assessment, a plan is made to empty the bladder before leakage would normally occur. Usually a schedule of going to the bathroom to attempt to void every 2 hours during the day is effective. Timed voiding is useful for those with impaired physical and mental functioning with all types of incontinence. The main difference between timed voiding and bladder training is that in timed voiding a schedule is made based on when the person normally urinates. In bladder training, a schedule is made to train the bladder to follow a predetermined schedule that is not based on how the person normally urinates.
  • Electrical stimulation is often done in conjunction with pelvic muscle exercises for those with urge and stress incontinence. Electrodes are temporarily placed into the vagina or rectum to stimulate and thereby strengthen nearby muscles. Therapy staff in some nursing homes utilize electrical stimulation.
  • A pessary is a stiff ring that is inserted by a physician or nurse into the vagina. It presses against the wall of the vagina and the nearby urethra. It helps to reposition the urethra, leading to less stress leakage from stress incontinence. It needs to be removed and cleaned monthly then reinserted. Some nursing homes have staff that are trained in the use of pessaries.
  • Medications have shown effectiveness to treat urge urinary incontinence. Detrol, Ditropan (and the patch form Oxytrol), Sanctura, Vesicare, Enablex are examples. They are contraindicated with urinary retention. Dry mouth, headache, constipation, and abdominal pain are common side effects of the oral form and skin irritation at the application site is a side effect of the Oxytrol patch.
  • Catheters should not be a routine treatment for incontinence, even temporarily. The only exception is for overflow incontinence, in which catheterization is the only treatment.
  • Absorbent pads may be useful as a comfort treatment. They are designed to absorb urine to protect the skin and clothing. The use of such pads should be limited to those who are unable to participate in a toileting plan.

How should the nursing home be assessing and treating my loved one with incontinence?

Residents in the nursing home should have their bladder function evaluated on admission, quarterly, and with changes in condition to assist in achieving and maintaining the highest level of continence possible. On admission, a three day bowel and bladder diary should be completed to assess the resident’s toileting patterns and for episodes of incontinence. This diary should also be completed with each change in condition, and upon discontinuation of a foley catheter. A post-void residual via in and out catheterization or bladder scan should also be completed. A toileting schedule should be developed based on the assessment. The care plan should be developed if necessary with the findings.

Questions you can ask the nursing home about urinary incontinence:

  • How does the nursing home determine the cause of loss of bladder continence?
  • How many residents are restrained, and what's the procedure for toileting them?
  • How often does staff help mobility impaired residents use the bathroom?
  • How does the nursing home help the resident restore bladder control?
  • How does the nursing home avoid complications such as pressure sores in these residents?

Resources

American Urogynecologic Society

American Urological Association (AUA)

National Association for Continence (NAFC)

Urology Channel

Maloney, C., & Cafiero, M. (1999). Implementing an incontinence program in long-term care settings. A multidisciplinary approach. Ju. Gerontol Nurs 25(6): 47-52.

Reznicek, S. B. (2002). Management of incontinence in the elderly. J. Gen Specif Med, 5(5): 43-48.

Weiss, B. D. (1998). The diagnostic evaluation of urinary incontinence in geriatric patients. Am Fam Phys, 57, 2675-2684.