Introduction
Urinary incontinence (UI) is the involuntary loss of urine from the bladder (Keilman, 2010). The International Continence Society (ICS) defines the condition as a complaint of involuntary leakage of urine (Abrams, 2002). The involuntary leakage may range from just a few drops to total emptying of the bladder. It can severely, adversely affect a person’s quality of life (QoL) (McCarthy, 2009).
Prevalence and Impact of UI
UI is a debilitating condition and can be quite distressful. The condition becomes more prevalent as the population ages; therefore, extremely common among the elderly (Abrams, 2002). UI is also twice more common in women than in men and has a prevalence ranging from about 20% in women aged 45 years or younger to about 30% in women aged 80 years or older (Landfeld, 2008). The prevalence increases with age with more than one-third of women older than 65 years of age experiencing some degree of UI; and about 12% reporting daily urine leakage (Kincade, 2007). It impacts life both physically and psychologically. In Australia specifically, UI affects about 13% men and 37% women (Australian Institute of Health and Welfare, 2006). Interestingly, about 70% of people do not seek consultation and treatment for their problem (Millard, 1998). Around 77% of nursing home residents in Australia are affected by the condition (Steel, 1995). The condition is associated with an increased utilization of health and social care, likelihood of institutionalization and considerable co-morbidity such as skin rashes, skin infections, depression, and urinary tract infection (Gadgil, 2008). In addition, most cases of UI are associated with the need for frequent, urgent trips to the bathroom. This particularly has been related to an increased risk of falls and fractures (Gadgil, 2008). UI sufferers suffer from feelings of embarrassment and anxiety. They have a decreased participation in social gatherings (Wyman, 1990). Moreover, there is associated financial burden in the form of cost of absorbent pads, treatment of the condition itself and its complications, and admissions to institutions. Thus, it proves to be a costly health problem particularly for women (Nygaard, 2007). The estimated costs are on rise causing excessive burden on patients and health care system. A study observed two – fold greater risk of nursing home admissions among women with UI compared to those without UI (Thom, 1997).
Types of UI and its Risk Factors
UI can be of several types, most common of which is urge UI and stress UI; or it can be both in the form of mixed UI. It can also be functional or overflow type, though these are not very common.
Urge UI - This is also termed as urgency incontinence or overactive bladder or even reflex incontinence. This is the primary cause of UI in older people. Urge UI can be due to over activity of the detrusor muscles of the bladder. Detrusor over activity is characterized by involuntary detrusor muscle contractions during the filling phase. It may have a neurogenic cause or can be idiopathic, but in majority of the cases, the cause is unknown (Santiagu, 2008). Parkinson disease or stroke may cause a loss of inhibitory neurons; leading to neurogenic detrusor over activity. Even if the bladder is not full, involuntary bladder contractions can occur. This leads to symptoms of urgency and frequency (Santiagu, 2008). Another risk factor that leads to urge UI is nocturnal polyuria that is defined as producing more than 35% of the total daily urine output at night. This is again a problem associated with later life. Changes in kidney physiology result in kidneys working harder at night to produce greater quantities of more dilute urine. This can lead to increased urgency of urination in the nights (Gadgil, 2008).
Stress UI – It is the involuntary leakage of urine during exertion or activities that increase intraabdominal pressure. The risk of this condition increases after pregnancy and after a vaginal delivery with a higher prevalence around menopause. Smoking and obesity are also some of the risk factors. The condition is due to weakness of the pelvic floor or sphincter. Several other risk factors may also be responsible that include postmenopausal involution of the urethra or as a complication of pelvic surgery or trauma (Santiagu, 2008).
Mixed UI – This type of UI is a combination of stress and urge UI where there is involuntary leakage with urgency and also with exertion, sneezing or coughing (Vasavada, 2013).
Functional UI – this type of UI is due to reasons other than neuro – urologic and urinary tract infections. The cause of this could be psychiatric disorders, delirium, or reduced mobility (Vasavada, 2013).
Overflow UI - This type of UI is caused by a hypotonic bladder, bladder outlet obstruction, or other forms of urinary retention. It results in lower urinary tract infection associated with loss of small amounts of urine. It is more common in men with benign prostatic hyperplasia (BPH) (DeMaagd, 2011).
Nursing Interventions
Nurses are always at the fore front of any medical care. They are in a pivotal role to try and decrease the direct and indirect costs due to UI through health promotion. The aim of treatment that a nurse can offer for UI is to reduce symptoms and improve the overall QoL. A nurse plays a vital role in educating the patient on lifestyle interventions, particularly weight loss and physical activity in morbidly obese patients (Santiagu, 2008). It helps reduce stress UI, and to a certain extent, urge UI too. Caffeine restriction may also reduce UI. Constipation and straining during defecation may increase the risk of pelvic organ prolapse leading to stress UI. Therefore, training the patient on pelvic floor exercise that involves strengthening the pelvic floor muscles helps to an extent. It needs to be continued for 3-4 months before determining its success. Bladder training is the initial treatment for UI, being noninvasive, inexpensive, and easy to perform. This includes a scheduled voiding program with gradual increases in the duration between voids, and urge suppression techniques with distraction or relaxation (Santiagu, 2008). A Cochrane review suggests bladder training may be more effective than placebo (Wallace, 2000). The practice of conservative management of UI is generally beneficial and effective; and needs to be encouraged. Nurses understand better, the efficacy and significance of lifestyle adjustments, behavior modifications, and non-pharmacologic interventions.
Implications for Nursing
With an increasing aging population, nurses can expect to see more people with UI and will have to become experts in providing quality and safe care to the aged. Understanding the situation of older people with UI and demonstrating care and concern is paramount in promoting QoL in this population. Therefore, timely and adequate education is crucial in the management of the condition (Keilman, 2010). It helps dispel perceptions and impacts compliance. Empowering older people through knowledge is in the hands of holistic nursing practice. Nurses certainly can make a difference in the management of the condition if they are aware of the essentials. The single most important action that a nurse can take is to ask every older adult about UI and then to follow the basic approaches to evaluation and management. If nurses spent quality time with UI sufferers, it is a significant observational clinical experience to them (Keilman, 2010). Ideally, the approach to UI should be from an interdisciplinary perspective where the nurse is ideally situated to practice holistically and provide the educational environment conducive to older adult learning. UI is the problem of the aged and with increased life expectancy, the people of the world are aging, thus making UI a global health concern that is here to stay (Keilman, 2010).
My views
As a nursing student, caring for patients with UI is a part of my everyday course. I am beginning to be aware of the extensive problems that an adult with UI has; and the effect of these problems on their overall QoL. Beyond the usual social and psychological problems, I have also noticed several other issues such as admission to nursing homes, poor general health and well-being, and cognitive impairment too, which may be a part of aging. I find it very necessary to have the knowledge and skills necessary to improve upon the outcomes for UI patients.
Generally, most older adults who experience UI also experience fecal incontinence. It is embarrassing to most of them to openly talk about their suffering; therefore, the treating physician needs to proactively enquire about any other symptoms when patients reports UI. Some feel they should tolerate their symptoms rather than shamelessly reporting it. For such reasons, UI goes unreported, and therefore, untreated. The way consequences like social stigmatization and isolation manifest itself is different for each patient and this should be taken into account when carrying out an individual and holistic continence assessment.
I understand a need to improve upon my knowledge of local policies and protocols; and about services available to patients with continence problems. I would also like to improve my understanding of quality of life assessments. I intend to gain knowledge on National Institute for Health and Clinical Excellence's (NICE) guidelines for continence care so that I can complete a more in-depth assessment of patient needs.
Conclusion
In conclusion, UI is a global problem, particularly with women, and can be tackled and managed efficiently with appropriate nursing interventions.
References
Abrams, P., Cardozo, L., Fall, M., et al. (2002). The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Am J Obstet Gynecol, 187, 116-26.
Australian incontinence data analysis and development. (2006) Australian Institute of Health and Welfare. Retrieved from: http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=6442455813; Accessed: 19th Oct, 2013.
DeMaagd G. A., Davenport, T. C. (2012). Management of Urinary Incontinence. PT, 37 (6), 345 – 61.
Gadgil, S. Wagg, A. (2008). Management of urinary incontinence in older people. Prescriber, 35 – 42.
Keilman, L.J., Karen, D. (2010). Knowledge, Attitudes, and Perceptions of APN Regarding Urinary Incontinence in Older Adult Women. Res Theory Nurs Prac, 24(4), 260 -79.
Kincade, J. E., Dougherty, M. C., Carlson, J. R., &Wells, E. C. (2007). Factors related to urinary incontinence in community-dwelling women. Urol Nursing, 27(4), 307-317.
Landefeld, C. S. (2008). National Institutes of Health state-of-the-science conference statement: prevention of fecal and urinary incontinence adults. Ann Intern Med, 148 (6), 449–58.
McCarthy, G., McCormack, B., Coffey, A., et al. (2009). Incontinence: Prevalence, management, staff knowledge and professional practice environment in rehabilitation units. Int J Older People Nurs, 4 (1), 3 - 11.
Millard, R. (1998). Prevalence of urinary incontinence in Australia. Aus Cont. J, 4, 92-99.
Nygaard, I., et al. (2007). Urinary Incontinence in Women. In: Litwin, MS.; Saigal, CS., editors. Urologic Diseases in America. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Washington, DC: US Government Printing Office; p. 159-191.
Santiagu, S. K., Arianayagam, M., Wang, A., Rashid, P. (2008). Urinary incontinence: Pathophysiology and management outline. Aust Fam Phy, 37 (3), 106 - 10.
Steel, J., Fonda, D. (1995). Minimising the cost of urinary incontinence in nursing homes. Pharmacol Economics, 7, 191 - 7.
Thom, D.H., et al. (1997). Medically recognized urinary incontinence and risks of hospitalization, nursing home admission and mortality. Age Ageing, 26 (5), 367–74.
Vasavada, S., P. (2013) Urinary Incontinence. Medscape. Retrieved from: http://emedicine.medscape.com/article/452289-overview; Accessed: 25th Oct, 2013.
Wallace, S.A., Roe. B., Williams, K., Palmer, M. (2000). Bladder training for urinary incontinence in adults. Update of Cochrane Database Syst Rev, CD001308.
Wyman, J.F., et al. (1990). Psychosocial impact of urinary incontinence in the community-dwelling population. J Am Geriatr Soc, 38(3), 282–8.
