Managing Urinary Incontinence Post Stroke Telehealth Presentation for Alberta Provincial Stroke Stra

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Managing Urinary Incontinence Post
StrokeTelehealth Presentation for Alberta
Provincial Stroke Strategy April 23, 2009

• Laura Robbs, RN, BScN, MN, ET, NCA
• Clinical Nurse Specialist-Continence, Trillium
  Health Centre
• Mississauga, Ontario

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Learning Objectives

• Review normal bladder function
• review common types of urinary incontinence
• Discuss the impact of stroke on urinary
  continence
• discuss strategies for promoting urinary
  continence post stroke

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What is urinary incontinence (UI)?

• It has been defined by the International
  Continence Society as
• a condition where involuntary loss of urine is a
  social or hygienic problem
• (ICS, 1988)

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Responses to UI

• Fear
• embarrassment
• shame
• anxiety
• frustration
• guilt
• anger

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Relationship between UI Quality of Life

• Greatest negative impact on emotional and social
  well being
• UI is embarrassing, socially disruptive with
  multiple effects on daily activities and
  interpersonal relationships
• does not appear to have devastating psychological
  consequences

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Who is affected by UI?

• General population
• 1 in 4 women
• 1 in 10 men
• post stroke
• 32-79 people on admission
• 25-28 on discharge
• ? risk of falls, fractures hospitalization
• triples the risk of long term care placement

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Bladder function

• Voluntary reflexive control
• Bladder - muscular balloon constantly filling
  under low pressure
• Bladder stretch receptors send impulse through SC
  to the brain
• stimulates a response causing bladder to contract
  allows external sphincter to relax

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Bladder function (continued)

• Therefore urine is expelled as the bladder
  contracts, internal sphincter opens external
  sphincter relaxes
• Key brain able to reduce urge and delay
  urination

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Emptying phase
Storage phase
Bladder pressure
Normal Micturition Cycle
Normal desire to void
First sensation to void
Bladder filling
Bladder filling
Detrusor muscle relaxes Urethral Sphincter tone
Pelvic floor tone
Detrusor muscle contracts Urethral Sphincter Rel
axes (Voluntary control) Pelvic
floor Relaxes MICTURITION
Detrusor muscle relaxed Urethral Sphincter contr
acts Pelvic floor contracts
Detrusor muscle relaxes Urethral Sphincter tone
Pelvic floor tone
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Bladder function storage voiding

• 400-600 ml maximum bladder capacity (less with
  aging)
• first desire to void at 300 ml
• normal voiding frequency 4-8 times per day and
  once at night

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CNS control of bladder
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CNS control of bladder functioning

• Cortical Centre
• frontal lobes are key to controlling the bladder
  by inhibiting detrusor (bladder muscle)
  contractions and their connection to the sacral
  roots via the SC is critical

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CNS control of bladder functioning

• Pontine centre
• receives input from the cerebral cortex
• coordinates detrusor contraction and urethral
  relaxation
• inhibitory impulses from the pontine centre
  allows bladder to store urine

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CNS control of bladder functioning

• Sacral Centre
• mechanism that mediates voiding in infants and in
  adults following SCI above the lumbosacral spinal
  segments

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Types of incontinence anyone can experience

• Stress
• urge
• overflow
• functional

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Stress incontinence

• Not related to CVA - most common UI in women
• sudden increase in intra-abdominal pressure
  (laugh, cough, exercise)
• related to weak pelvic floor muscles, loss of
  estrogen, positioning of bladder or urethra
• Can occur in men post radical prostatectomy

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Urge incontinence

• Loss of urine with a strong unstoppable urge to
  urinate
• SS frequency day night, UI on way to
  bathroom, small voided volumes, common in men
  women
• Common in neurological injury/condition e.g. CVA
• Also known as overactive bladder

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Overflow Incontinence

• Bladder full at all times leaks any time
• related to partial obstruction of bladder neck
  (e.g. enlarged prostate, pelvic prolapse in
  women), secondary to medication, fecal
  impaction, diabetes or lower SCI
• SS dribbling, urgency, frequency, hesitancy

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Functional Incontinence

• UI that results from barriers that prevent the
  person from getting to the BR in time
• e.g. impaired cognitive functioning
  (Alzheimers), or impaired physical functioning
  (arthritis)

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Stroke UI depends on part of brain affected
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How strokes affect UI

• FRONTAL STROKE
• voluntary control of the external sphincter but
  uninhibited bladder contraction
• strong urge to void with short/no warning
• persistent frequency, nocturia, urge incontinence

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Parietal Basal Ganglion Stroke

• Uninhibited bladder contraction
• voiding is obstructed as the bladder and
  urethral sphincter contract at the same time
• may lead to ureter reflux and renal damage
• overflow incontinence

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Hemispheric Stroke

• Secondary to immobility and dependency on others
  rather than direct effects from the stroke

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Additional risk factors for UI

• Urinary tract infections
• caffeine intake
• low fluid intake
• constipation
• weak pelvic floor muscles

• mobility impairment
• cognitive impairment
• environmental barriers
• medications e.g. diuretics, sedatives

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Assessment of Urinary Incontinence

• Incontinence history
• Fluid intake
• Bowels
• Medical history
• Medications
• Functional ability
• Voiding record

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Incontinence History

• Onset
• Duration
• Daytime/nighttime
• Accidents
• Stress loss
• Urge loss
• Aware of loss?

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Fluid intake

• How much
• Restrictions
• Caffeine
• alcohol

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bowels

• Pattern
• Constipation
• Diet
• Laxatives

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Medical history

• Stroke
• Parkinsons
• Multiple Sclerosis
• Diabetes
• Repeated urinary tract infections
• Acquired brain injury
• Dementia

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medications

• Diuretics
• Anticholinergics
• Estrogen
• Sedatives/hypnotics
• Antidepressants

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Functional ability

• Access to bathroom
• Ambulation
• Needs assistance
• wheelchair

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Impact of cognitive impairment on ability to be
continent

• Ability to follow understand prompts or cues
• Ability to interact with others
• Ability to complete self care tasks
• Social awareness

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Physical assessment

• Post residual volume
• urine culture
• vaginal examination
• rectal examination
• Voiding record
• time and amount of fluid intake, urine voided,
  incontinence x 3-4 days

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Conservative treatment all team members can do

• Client/family focused
• using education
• behaviour modification
• problem solving strategies

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Fluid intake changes

• Reduce/eliminate caffeine intake
• reduce/eliminate alcohol intake
• ensure adequate fluid intake
• (1500-2000 ml)
• Temporarily reduce intake when going out
  (urgency)
• Nothing to drink two hours prior to going to bed
  for the night

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Pelvic muscle exercises (Kegels)

• Strengthen pelvic floor muscles
• helps with stress or urge UI
• need more than verbal instruction
• Tighten anal sphincter as if you do not want to
  pass rectal gas
• hold contraction for count of 3 then relax for 3

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Urge suppression strategies

• pelvic floor exercises
• urge suppression using distraction techniques
• aim gradually ? voiding intervals voiding
  volumes (300-400 ml)
• voiding/prompted voiding q 3 hours

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Treatment Medications Anticholinergics

• Reduce irritability of the bladder
• larger bladder volumes
• reduces frequency
• Available in long acting dose
• e.g. Oxybutinin(Ditropan), Tolterodine (Detrol),

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Anticholinergics

• potential side effects
• dry mouth
• drowsiness, fatigue
• altered mentation with diminished ability for
  complex problem solving
• hypertension, tachycardia
• insomnia

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Treatment Medications Estrogen

• Local estrogen cream, suppositories or estring
  helpful with atrophic vaginal changes
• help with symptomatic complaints of dryness, UI,
  UTI

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Toileting strategies less severely cognitively
impaired more mobile benefit more

• Timed voiding
• Person is toileted on a schedule voiding
  recorded on chart
• Their schedule can be gradually adapted to match
  their individualized voiding schedule
• Prompted voiding
• person again toileted on regular schedule but is
  asked if they need assistance

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Prompted voiding

• ? number of incontinent episodes/day ? number
  of continent voids
• Can be used with people with physical or mental
  impairments
• Identification of individual voiding patterns
  rather than routine toileting e.g. q2h can be
  more successful
• Determine individual voiding pattern by voiding
  record

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Vaginal pessaries

• Worn intra-vaginally to support cystocele or
  uterine prolapse

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Products

• Use pads made for urine loss
• not menstrual pads, facecloths or tissue
• pads for men
• Night time briefs helpful during heavier wetting
  times
• use unscented, mild soap sparingly

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Referral to medical specialist (urologist,
urogynecologist, gynecologist)

• Significant post void residual
• abnormal urine dipstick test
• pelvic organ prolapse
• constant dribbling
• frequent UTIs
• No response to conservative treatment

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Questions/Comments?

• Laura Robbs, Clinical Nurse Specialist-Continence
• Trillium Health Centre
• 905-848-7580 ext. 3267
• lrobbs_at_thc.on.ca

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References

• Coleman Gross, J. (2003). Urinary incontinence
  after stroke Evaluation and behavioral
  treatment. Topics In Geriatric Rehabilitation.
  19(1) 60-84.
• Harari, D., Norton, C., Lockwood, L., Swift, C.
  (2004). Treatment of constipation and fecal
  incontinence in stoke patients Randomized
  control trial. Stroke. 35(11) 2529-2555.
• Smith, T.L. (2008). Medical complications of
  stroke. Up To Date. www.uptodate.com