Promoting Continence: Simple Strategies with Major Impact

  Urinary incontinence is a common problem, especially among women, yet it remains underreported and undertreated. This is partly due to patients’ beliefs that little can be done and partly due to healthcare professionals’ perception that treatment is limited to surgery, advanced behavioral strategies requiring specialized equipment, or containment devices.

Nurses are in a strategic position to reduce the incidence of incontinence by teaching bladder health strategies (ie, fluid management, appropriate voiding intervals, constipation prevention, weight control, smoking cessation, and pelvic muscle exercises), actively assessing patients for incontinence, and initiating appropriate referrals and primary interventions. Patients with significant neurologic deficits, structural abnormalities such as pelvic organ prolapse, or urinary retention should be referred for further workup. However, most patients can be treated with primary continence restoration strategies, which include identifying and correcting reversible factors such as urinary tract infection or atrophic urethritis; instruction in pelvic floor muscle exercises; and instruction regarding urge inhibition strategies. Implementing these simple strategies can significantly improve bladder function and continence in the majority of patients.

  Urinary incontinence (UI) is a common problem, especially among middle-aged and older women. Studies indicate that at least 35% of community-dwelling women over the age of 65 are incontinent, and these numbers are expected to increase as the Baby Boomer generation ages.^1,2 Urinary incontinence is costly. In addition to expenses associated with management of the condition (surgery, pharmaceuticals, containment and absorptive products), increased incidence of urinary tract infections, falls, and skin breakdown also exact a financial toll. However, the most significant cost may be in terms of quality of life — incontinence is associated with anxiety, depression, and social isolation that becomes more pronounced as the condition worsens.^3-6

  Underreporting and undertreating incontinence continue to be major problems, probably due, in part, to patients’ (and many healthcare professionals’) belief that UI is an inevitable consequence of aging, especially for women.⁶ In addition, many healthcare providers perceive incontinence as an incurable and primarily hygienic problem; therefore, they neither actively screen for the condition nor proactively educate patients regarding its prevention and management. Even WOC (ET) nurses and other specialists, who are more knowledgeable regarding continence care, frequently view continence care as difficult and high-tech, requiring expertise in urodynamics, biofeedback, and electrical stimulation.⁷ All of these factors contribute to a lack of consumer education regarding continence promotion and a passive approach to management of existing incontinence.

  Nurses are in a strategic position to change this state of affairs through the implementation of simple strategies that focus on continence promotion, casefinding, implementation of primary care strategies for patients with uncomplicated incontinence, and referrals for patients with neurologic deficits or structural defects. This article focuses on simple strategies that have a powerful impact on the promotion or restoration of continence.

Strategy #1. Continence Promotion: Incorporate Bladder Health Strategies into Routine Healthcare

  Fluid intake. Encourage patients to maintain adequate fluid intake — ie, 30 cc/kg body weight/day (unless contraindicated). This level of fluid intake promotes renal clearance of solutes and maintains appropriately dilute urine that helps reduce bladder irritability and symptoms of urgency and frequency.⁵ Patients should be taught that water-based fluids are particularly beneficial for maintaining hydration and preventing bladder irritability and that caffeinated and alcoholic fluids have been shown to contribute to increased sensory urgency in vulnerable individuals.⁸ In addition, patients should be encouraged to drink fluids throughout the day to avoid episodic dehydration.

  Voiding intervals. Encourage patients to void at regular intervals — eg, every 3 to 4 hours during waking hours. Regular voiding prevents chronic bladder distention and its sequelae⁹ — ie, compromised detrusor contractility (due to overstretching of the muscle fibers), urinary tract infection (due to stasis and a poorly perfused bladder wall), and leakage with activity (due to elevated intravesical pressures).

  Bowel function. Teach patients strategies to maintain normal bowel function. These include adequate intake of fiber and fluids, routine exercise, and appropriate use of laxative agents. It is particularly important for women to prevent chronic constipation because straining at stool is a risk factor for stress incontinence due to loss of normal pelvic muscle tone.¹⁰ In addition, chronic constipation is a risk factor for urge pattern incontinence, because a chronically full rectum interferes with normal bladder distention and increases bladder irritability.¹¹ The classic “prescription” for prevention of constipation is 28 to 30 g of fiber/day coupled with adequate fluid intake. The recommended amount of fiber can be obtained through dietary modifications or by routine intake of bulk laxatives or bran mixtures¹² (see Table 1). Individuals who experience persistent constipation despite adequate fiber, fluid, and activity require further evaluation to rule out constipation-predominant Irritable Bowel Syndrome or slow-transit constipation. These individuals should be referred to a gastroenterologist and will probably require the addition of osmotic laxatives (eg, magnesium citrate, lactulose, sorbitol, or polyethylene glycol solutions) to maintain normal bowel function.¹³

  Weight. Encourage weight control. Obesity is associated with increased intra-abdominal pressure, which increases the risk for stress incontinence (as well as many other medical problems).^10,14 Key strategies for weight control include routine exercise and a high-fiber, low carbohydrate diet, both of which also contribute to bowel health.

  Smoking. Discourage smoking and recommend smoking cessation programs for individuals who are interested in stopping. Explain that smoking increases the risk for bladder and cervical cancer as well as lung cancer and that the chronic cough experienced by many long-term smokers contributes to pelvic muscle laxity and stress incontinence.^10,14

  Pelvic muscle exercise. Teach women to routinely perform pelvic muscle exercises to strengthen the pelvic floor muscles and to build endurance.^4,10 Explain that the muscles of the pelvic floor play a critical role in supporting the bladder and urethra in position and in maintaining continence during periods of increased intra-abdominal pressure (by opposing descent of the bladder and urethra and by compressing the urethral walls to prevent leakage).^15,16 Instruction in pelvic muscle exercises can be incorporated into routine gynecologic care and health teaching for women, who should be taught how to ensure contraction of the appropriate muscles and to perform exercises that build endurance as well as strength. Pelvic muscle exercises are discussed in more detail in the section on Strategy #4: Continence Restoration.

Strategy #2. Casefinding: Incorporate Questions about Bladder Function and Continence into Admission Assessments

  Currently, incontinence seems to fall into the realm of “Don’t ask, don’t tell.” Incorporating questions designed to identify individuals with incontinence changes patients’ perspectives that nothing can be done and identifies individuals at an earlier stage when intervention can hopefully prevent progression.¹⁰

  The Association of Women’s Health, Obstetric, and Neonatal Nurses conducted research into female UI that focused on strategies that 1) would improve casefinding and management of women with incontinence and 2) could be incorporated into routine gynecologic care.^6,17 They developed a simple tool to identify women with incontinence who might not report the condition on their own. The tool could be incorporated into health history forms routinely used in outpatient settings and includes the following screening questions:
    1. Do you ever leak urine/water when you don’t want to?
    2. Do you ever leak urine/water when you cough, laugh, or exercise?
    3. Do you ever leak urine/water on the way to the bathroom?
    4. Do you ever use pads, tissue, or cloth in your underwear to catch urine?

  This tool was found to be an effective casefinding approach: 57% of the women in their study reported incontinence; whereas, studies have shown that the percentage of incontinent individuals who report their condition to a healthcare provider averages 40%.¹⁷ Czarapata³ has found the following questions to be effective casefinders:
    1. Do you have the need to urinate so urgently that you are afraid you might not make it to the bathroom?
    2. Do you have loss of urine when you laugh or cough?
    3. Do you have the need to wear an absorbent pad to protect your clothing against loss of urine?
    4. Do you have the need to alter any plans or activities because you are afraid of leaking urine?
    5. Do you have the need to urinate more frequently?

  These or similar questions could be incorporated into health assessments in all care settings to improve identification of individuals with bladder control problems.

Strategy #3. Referrals: Refer Patients with Structural Problems, Evidence of Retention, or Neurologic Compromise

  While most patients can be cured or significantly improved with simple behavioral strategies, some patients need further evaluation and/or have problems that may require surgical intervention. These include patients with significant neurologic lesions causing denervation to the bladder and sphincter, patients with urinary retention, and patients with structural defects such as pelvic organ prolapse, cystocele, or rectocele.^5,8,9,15,18 To identify patients with neurologic lesions, the clinician should ask the patient if multiple sclerosis, Parkinson’s Disease, spinal cord lesions, stroke, back injuries or back surgery, or diabetic neuropathy are part of his/her health history. Patients with a history of neurologic disease and patients who present with the triad of bladder dysfunction, bowel dysfunction, and sexual dysfunction should undergo neurologic evaluation.⁸

  To assess for urinary retention, the clinician should ask the patient about sensations of incomplete emptying and recent urinary tract infections. Populations considered at high risk for retention include patients with neurologic lesions, women with pelvic organ prolapse, older men, and individuals with recurrent urinary tract infections. High risk patients and those with sensations of incomplete emptying should undergo further evaluation— ie, post-void residual urine measurement and/or urodynamic evaluation.⁸ It is important to note that the clinical presentation of chronic urinary retention is similar to that of overactive bladder. Urgency, frequency, low voided volumes, and nocturia are common findings with both conditions. Failure to assess for retention could lead to inappropriate treatment; thus, assessment for evidence of retention is a critical component of any screening evaluation.

  A simple pelvic examination is used to rule out cystocele, rectocele, and pelvic organ prolapse. Clinicians who suspect neurologic conditions, structural defects, or retention but who are unable to conduct the necessary assessment should refer the patient to a practitioner or center prepared to conduct a comprehensive evaluation.

Strategy # 4. Continence Restoration: Implement Primary Interventions for Restoration of Continence for Patients with Uncomplicated Incontinence

  The AHCPR Guidelines recommend behavioral strategies as the preferred initial treatment strategy for the majority of patients with UI. Studies indicate that behavioral therapies provide positive outcomes with no adverse effects for individuals with stress incontinence (ie, leakage associated with activities such as coughing, laughing, or sneezing), urge pattern incontinence, (ie, leakage associated with a strong sense of urgency to void and inability to reach the toilet in time to prevent incontinence), and mixed stress-urge incontinence.^1,19 Because stress, urge, and mixed incontinence are the most common types of incontinence, it is evident that the majority of individuals with UI can benefit significantly from simple behavioral therapies.^1,6,14

  Assess for and address reversible factors. A number of reversible factors contribute to urinary leakage, so every patient with complaints of urinary leakage should first be screened for reversible factors and these factors corrected.⁵ ResnickMsup>20 has coined the acronym DIAPPERS to help clinicians remember the eight reversible factors: delirium, infection (or irritants), atrophic vaginitis, pharmaceuticals, psychologic issues, endocrine problems leading to excess urine production, restricted mobility, and stool impaction. Another acronym that is used as a tool to remember/identify reversible factors is DRIP: D is a prompt to screen for delirium, dementia, depression, and dehydration; R is a prompt for restricted mobility, rectal impaction, and retention; I prompts for irritation, infection, and inflammation; and P prompts for polyuria and pharmacologic agents.³ The most common reversible factors that impact continence, along with implications for nursing management are listed in Table 2.

  Teach pelvic floor muscle exercises (PFMEs) to patients with stress, urge, or mixed pattern incontinence. The term pelvic floor encompasses the muscles, ligaments, and fascial structures that act in concert to support the pelvic organs in position and provide compressive force to the urethra during periods of increased abdominal pressure. An intact and functional pelvic floor requires intact fascial structures as well as strong pelvic muscles to oppose downward movement of the bladder and urethra when the abdominal pressure rises. The fascial structures connect the bladder and urethra to the pelvic sidewalls and provide attachments for the muscles, and the muscles provide the lift needed to oppose rising abdominal pressures and bladder descent.^{15,16,21–23} In contrast, a damaged or weakened pelvic floor is unable to provide the needed support and opposing lift — as a result, activities that increase abdominal pressure cause the bladder and urethra to drop out of position, and the downward pressure exerted against the bladder results in urinary leakage (because the damaged pelvic floor is unable to provide sufficient urethral compression).

  The pelvic floor muscles surround the urethra, vagina, and anus; they are known collectively as the levator ani. These muscles contract in concert to lift the urethra, vagina, and rectum simultaneously (assuming that their fascial attachments are intact). These muscles are predominantly (about 70%) composed of Type I (slow-twitch) muscle fibers and the remainder are Type II (fast-twitch). Type I muscle fibers provide sustained support and are fatigue-resistant, while Type II fibers provide the rapid compressive force needed to oppose leakage during increased abdominal pressure.^{22, 24} In addition to providing urethral support and compression, contracting the pelvic muscles induces a reflex relaxation of the detrusor muscle. Thus, a well-toned pelvic floor is beneficial in the management of urge and mixed stress-urge incontinence, as well as stress incontinence.²⁵

  Pelvic muscle exercises are generally thought to be beneficial in the management of both stress and urge incontinence; however, clinicians do not agree on the optimal protocol and technique for teaching pelvic muscle exercises.^22,24 All studies support the importance of helping the patient to accurately isolate the pelvic floor muscle group^3,5; techniques for ensuring contraction of the correct muscle group are outlined in Table 3. It is also acknowledged that the exercise program should include maneuvers designed to strengthen both the slow-twitch (Type 1) and the fast-twitch (Type II) muscle fibers.^22,24 Although more data are needed before an optimal protocol can be identified, it is clear from many studies that any protocol involving isolation of the pelvic floor muscles and a graduated program with progressively lengthened contractions has a positive impact on continence (see Table 4).^5,22,24-27

  One beneficial aspect of pelvic muscle rehabilitation is now known as the “knack,”¹⁴ which simply involves teaching the patient to volitionally contract the pelvic floor muscles before engaging in activities that increase abdominal pressure, such as coughing, laughing, or lifting. Some evidence indicates that the pelvic floor reflexly contracts during periods of increased abdominal pressure in continent women and that this reflex is lost in incontinent women.¹⁵ Volitional contraction fills this “gap” and helps maintain continence.

  Teach patients with urge pattern incontinence bladder control/urge inhibition strategies. The causes of overactive bladder and urge pattern incontinence are not well understood, but the benefits of behavioral therapy in managing this condition are clear. The majority of patients with urge pattern incontinence are able to reduce frequency and control urgency using urge inhibition strategies. These strategies require the individual to resist the impulse to hurry to the bathroom in response to the urge to void — rather, the patient is instructed to utilize relaxation, pelvic muscle contractions, and/or distraction to control the urgency and delay voiding.^5,28 Typically, patients are encouraged to sit (if possible) and focus on deep breathing/relaxation or to use a series of pelvic muscle contractions to induce detrusor relaxation; both of these strategies have been utilized successfully in a number of studies.^5,11,25,28 A third strategy is distraction. Patients are encouraged to make a phone call, read a book, or otherwise distract themselves to reduce sensory awareness of bladder filling, and thus delay voiding. Patients can use whatever combination of these strategies works best to control their voiding patterns.

Conclusion

  Urinary incontinence is a common condition with profoundly negative effects on quality of life, yet underreporting and undertreatment remain common issues. Nurses are in a strategic position to teach individuals strategies that promote continence across the lifespan and to incorporate casefinding queries into their routine admission assessments (whether in acute care, home care, outpatient clinics, or long-term care). When continence problems are identified, nurses can implement primary continence restoration strategies or referrals as indicated. Simple strategies that restore or improve continence in a majority of patients include correction of reversible factors (DIAPPERS), pelvic muscle exercise programs (assuming intact and contractile muscles), and urge inhibition strategies.

   Ms. Doughty is Director, Emory University Wound Ostomy Continence Nursing Education Center, Atlanta, Ga. Please address correspondence to: Dorothy B. Doughty, MN, RN, CWOCN, FAAN, Emory University WOC Nursing Education Center, Room AT 732, 1365 Clifton Road NE, Atlanta, GA 30322; email: ddoughty@emory.edu.

1. Urinary Incontinence Guideline Panel. Pub. No. 96-0686. Managing acute and chronic urinary incontinence .Rockville, Md: US Department of Health and Human Services. Agency for Health Care Policy and Research; March 1996. AHCPR Publication No. 96-0686.

2. Thom D. Variation is estimates of urinary incontinence prevalence in the community: effects of differences in definition, population characteristics, and study type. J Am Geriatr Soc. 1998;46:473–480.

3. Czarapata B. Managing urinary incontinence. Patient Care for the Nurse Practitioner. 1999;April:37–48.

4. Smith D. Bladder Control is No Accident. Bend, Ore.: Deschutes Medical Products; 2001.

5. Hiser V. Nursing interventions for urinary incontinence in home health. JWOCN. 1996;26(3):142–160.

6. Sampselle C, Wyman J, Thomas K, et. al. Continence for women: evaluation of AWHONN’s Third Research Utilization Project. JWOCN. 2000;27(2):100–108.

7. Wound Ostomy Continence Nurses Society. Position statement: role of wound, ostomy, and continence nurses in continence management. Laguna Beach, Calif.: WOCN Society;1996.

8. Gray M, Haas J. Assessment of the patient with urinary incontinence. In: Doughty D (ed). Urinary and Fecal Incontinence: Nursing Management, 2nd ed. St. Louis, Mo.: Mosby; 2000:209–284.

9. Doughty D. Retention with overflow. In: Doughty D (ed). Urinary and Fecal Incontinence: Nursing Management, 2nd ed. St. Louis, Mo.: Mosby; 2000:159–181.

10. Johnson S. From incontinence to confidence. Am J Nurs. 2000;100(2):69–75.

11. Smith D. Urge incontinence. In: Doughty D (ed). Urinary and Fecal Incontinence: Nursing Management, 2nd ed. St. Louis, Mo.: Mosby; 2000:91–103.

12. Waldrop J, Doughty D. Pathophysiology of bowel dysfunction and fecal incontinence. In: Doughty D (ed). Urinary and Fecal Incontinence: Nursing Management, 2nd ed. St. Louis, Mo.: Mosby; 2000:325–352.

13. Doughty D. When fiber is not enough: current thinking on constipation. Ostomy/Wound Management. 2002;48(12):30–41.

14. Newman, D. Stress urinary incontinence in women. Am J Nurs. 2003;103(8):46–54.

15. Miller J. Criteria for therapeutic use of pelvic floor muscle training in women. JWOCN. 2002;29(6):301–311.

16. Sampselle C, DeLancey J. Anatomy of female continence. JWOCN. 1998;25:63–74.

17. Sampselle C, Wyman J, Thomas K, et al. Continence for women: a test of AWHONN’s evidence-based protocol in clinical practice. JWOCN. 2000;27(2):109–117.

18. Rovner E. Pelvic organ prolapse: a review. Ostomy/Wound Management. 2000;46(12):24–39.

19. Dierich M. A retrospective review of outcomes in one clinic’s treatment of urinary incontinence. Urologic Nursing. 1998;18(4):283–287.

20. Resnick N. Geriatric incontinence. Urology Clinics of North America. 1996;23:55–74.

21. Getliffe K, Dolman M. Normal and abnormal bladder function. In: Getliffe K, Dolman M, eds. Promoting Continence, 2nd ed. London, UK: Balliere Tindall; 2003:21–51.

22. Johnson V. How the principles of exercise physiology influence pelvic floor muscle training. JWOCN. 2001;28(3):150–155.

23. Haab F, Traxer O, Ciofu C. Tension-free vaginal tape: why an unusual concept is so successful. Curr Opin Urol. 2001;11(3):293–297.

24. Johnson V. Effects of a submaximal exercise protocol to recondition the pelvic floor musculature. Nurs Res. 2001;50(1):33–41.

25. Dattilo J. A long-term study of patient outcomes with pelvic muscle reeducation for urinary incontinence. JWOCN. 2001;28(4):199–205.

26. Boyington A, Dougherty M. Pelvic muscle exercise effect on pelvic muscle performance in women. Int Urogynecol J. 2000;11:212–218.

27. Dougherty M. Current status of research on pelvic muscle strengthening techniques. JWOCN. 1998;25:75–83.

28. Burgio K, Locher J, Goode P, et al. Behavioral versus drug treatment for urge urinary incontinence in older women. JAMA. 1998;280(23):1995–2000.