Title: Managing Urinary Incontinence Post Stroke Telehealth Presentation for Alberta Provincial Stroke Stra
1Managing 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
2Learning 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
3What 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)
4Responses to UI
- Fear
- embarrassment
- shame
- anxiety
- frustration
- guilt
- anger
5Relationship 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
6Who 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
7Bladder 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
8Bladder 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
9Emptying 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
10Bladder 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
11CNS control of bladder
12CNS 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
13CNS 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
14CNS 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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16Types of incontinence anyone can experience
- Stress
- urge
- overflow
- functional
17Stress 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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20Urge 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
21Overflow 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
22Functional 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)
23Stroke UI depends on part of brain affected
24How 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
25Parietal 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
26Hemispheric Stroke
- Secondary to immobility and dependency on others
rather than direct effects from the stroke
27Additional 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
28Assessment of Urinary Incontinence
- Incontinence history
- Fluid intake
- Bowels
- Medical history
- Medications
- Functional ability
- Voiding record
29Incontinence History
- Onset
- Duration
- Daytime/nighttime
- Accidents
- Stress loss
- Urge loss
- Aware of loss?
30Fluid intake
- How much
- Restrictions
- Caffeine
- alcohol
31bowels
- Pattern
- Constipation
- Diet
- Laxatives
32Medical history
- Stroke
- Parkinsons
- Multiple Sclerosis
- Diabetes
- Repeated urinary tract infections
- Acquired brain injury
- Dementia
33medications
- Diuretics
- Anticholinergics
- Estrogen
- Sedatives/hypnotics
- Antidepressants
34Functional ability
- Access to bathroom
- Ambulation
- Needs assistance
- wheelchair
35Impact 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
36Physical 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
37Conservative treatment all team members can do
- Client/family focused
- using education
- behaviour modification
- problem solving strategies
38Fluid 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
39Pelvic 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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41Urge 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
42Treatment Medications Anticholinergics
- Reduce irritability of the bladder
- larger bladder volumes
- reduces frequency
- Available in long acting dose
- e.g. Oxybutinin(Ditropan), Tolterodine (Detrol),
43Anticholinergics
- potential side effects
- dry mouth
- drowsiness, fatigue
- altered mentation with diminished ability for
complex problem solving - hypertension, tachycardia
- insomnia
44Treatment Medications Estrogen
- Local estrogen cream, suppositories or estring
helpful with atrophic vaginal changes - help with symptomatic complaints of dryness, UI,
UTI
45Toileting 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
46Prompted 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
47Vaginal pessaries
- Worn intra-vaginally to support cystocele or
uterine prolapse
48Products
- 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
49Referral 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
50Questions/Comments?
- Laura Robbs, Clinical Nurse Specialist-Continence
- Trillium Health Centre
- 905-848-7580 ext. 3267
- lrobbs_at_thc.on.ca
51References
- 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