Despite recent studies documenting serious complications, indwelling catheters continue to be a common intervention in the management of urinary incontinence.1*2 The indications for the use of chronic indwelling catheters include:
1 . Patients with urinary retention (that cannot be treated medically or surgically) of such severity that it causes recurrent symptomatic urinary tract infections or hydronephrosis;
2. Patients with skin rashes, ulcers, or wounds that are irritated by frequent contact with urine;
3 . Terminally ill patients for whom frequent bed changes are painful or uncomfortable; and
4. Patients who are at high-risk of skin breakdown due to malnutrition or steroid therapy.3,4
Close to one-half of nursing home patients have some degree of urinary incontinence;5"7 2% to 50% of these patients are managed by chronic indwelling catheterization.3,5,7 Between 25% and 50% of acutely hospitalized elderly patients have an indwelling catheter at some time during their hospitalization.8 Many of these patients may be discharged with the catheter in place or very shortly after it is removed.
Recent reports have suggested that the vast majority of incontinent patients, especially in nursing home settings, do not have an appropriate indication for a chronic indwelling catheter.3,9 Given the indications, to what can the frequency of indwelling catheter usage be attributed? The fact that indications for indwelling catheters in most nursing home patients are not documented7,9 implies that factors other than those dictated by diagnosis may be operant. Staff convenience is one possible factor. Reduction in the number of wet beds caused by incontinent episodes via the use of the indwelling catheter diminishes the workload and can thereby diminish costs of incontinence care (excluding complications).10 With expanded knowledge about the complications of indwelling catheter usage, including fever, bacteremia, acute and chronic pyelonephritis, urethral abscesses, bladder and renal stones, renal failure, and death,1 long-term reliance on this intervention should be viewed with caution.
There are many different treatments focused on alternatives to catheter usage for incontinent patients. Several recent reviews have addressed these alternatives in detail.6,11,12 As alternative treatments are implemented, fewer incontinent people will be subject to acute and chronic indwelling catheterization usage.
Little attention has been given to the possibility of weaning the catheterized patient from the use of an indwelling catheter. In light of the dangers of indwelling catheter use, and the increasing numbers of patients being discharged early from acute hospitals (under the auspices of DRG dictates) with indwelling catheters still in place or removed on the last day of hospitalization, specific bladder retraining programs are greatly needed.
The challenges of developing a postindwelling catheter bladder training protocol are twofold. There is a need to develop:
1. A practical protocol that can be implemented by nursing staff in the acute hospital and the nursing home setting, or by visiting nurses in the home setting; and
2. Methods of identifying appropriate candidates for such a training protocol.
Existing nosology for bladder training programs is confusing.2,6,13 Much of what is deemed bladder training is, in fact, merely training staff to get patients to the toilet on time by following a simple schedule of toileting once every two hours.2 Bladder training procedures can be broken down into three distinct, but overlapping, types of programs: scheduled toileting, habit training, and bladder retraining. Several studies have indicated that these procedures can be of value.1318 Table 1 illustrates several key differences among these procedures. Scheduled toileting essentially consists of a fixed toileting schedule coupled with techniques to trigger voiding and emptying the bladder completely. Habit training includes a variable toileting schedule based on patient need, triggering and emptying techniques, and positive reinforcement. Both of these techniques may also incorporate modifications in the timing, nature, and amount of fluid intake. The objective of these two techniques is to keep the patient and the bed or chair dry.
KEY FEATURES OF THREE BLADDER TRAINING PROGRAMS
In contrast to the scheduled toileting and habit training techniques, the objective of a bladder retraining program is to allow the patient to restore a normal pattern of voiding and continence. It requires adequate cognitive function, mobility, dexterity, and motivation of the patient. Bladder retraining involves an interplay of methods such as the progressive lengthening of between- void intervals; triggering and bladder emptying techniques; in-and-out intermittent catheterization, if indicated; and adjustments of the timing and amount of fluid intake. Although many programs recommend a clamping routine before catheter removal, few studies have validated this procedure.19
Post-Catheter Bladder Retraining Protocol
Table 2 details an example of a bladder retraining protocol. Concomitant with implementation of any such protocol is the need to assess incontinence continuously. The Figure illustrates an example of a bladder and bowel record that can be helpful for these assessments.19 The use of records such as the Incontinence Monitoring Record provides information that describes the frequency, amount, and timing of incontinence episodes. This information is helpful in assessing incontinent patients, monitoring responses to various interventions including bladder retraining, and providing the staff the opportunity for meaningful input into and feedback from the program.6,20,21 This type of detailed record, which includes space to measure voided volumes, is critical to the successful implementation of a retraining program.
A postcatheter bladder retraining program should be considered for any patient for whom a specific indication for continuous indwelling catheterization does not exist. A thorough genitourinary evaluation and a careful assessment of the patient's mental, physical, and functional status, as each relates to toileting skills, are essential in identifying appropriate candidates for a bladder retraining program.
At least two weeks are recommended for implementation of bladder retraining; the actual time span will depend on the patient. In addition to functional abilities and motivation, variance in length of prior indwelling catheterization may predict different bladder retraining outcomes. After a period of six to 12 months of indwelling catheterization, bladder capacity is significantly reduced, and permanent bladder wall changes can be documented.9 Patients with small bladder capacities may respond less well to training programs.22
The following case examples illustrate how a bladder retraining program might be implemented.
Case 1 - A generally healthy 75-yearold man was hospitalized after falling and fracturing his hip. He underwent surgical internal fixation and postoperatively developed urinary retention with overflow incontinence. This incontinence was attributed to immobility, narcotic analgesics, and mild BPH; and was managed by an indwelling catheter. Ten days after surgery, with the indwelling catheter still in place, he was transferred to a nursing home for rehabilitation. The indwelling catheter was removed, and a bladder retraining program was begun with in-and-out catheterization performed every eight hours. He was also treated for a urinary tract infection. After ten days the infection had resolved, but in-and-out catheterization was still necessary as residual volumes were significant (400 cc to 500 cc). Using techniques to prompt voiding, his voided volumes increased and his incontinence episodes decreased over the next several days. In-and-out catheterization was reduced to twice per 24-hour period with residual volumes of approximately 200 cc. Because of the persistent residuals, the patient underwent a urological evaluation, including cystoscopy, cystometrogram, and pressure flow studies, which revealed no anatomic obstruction. Bladder retraining was continued for another two weeks whereupon the patient was continent, infection-free, and voiding every three to four hours with residual volumes under 100 cc.
Case 2 - A 70-year-old woman was hospitalized for bladder neck suspension surgery. Four years before admission she first experienced stress incontinence, which was treated with pelvic floor exercises. The increased frequency of incontinence episodes over the next few years compromised the quality of her life and led her to accept surgical intervention. Postoperatively, she was only able to void small amounts of urine; suffered frequency, urgency, and urge incontinence; and had residual volumes over 200 cc. She was taught self-intermittent catheterization and was placed on a bladder retraining program before discharge home. Over the next several days, her voided volumes increased and her residual volumes decreased. Three weeks later, she had regained continence, her residual volumes were under 100 cc, and intermittent catheterization was no longer necessary.
Case 3 - An 88 -year-old man was admitted to the hospital following an acute stroke with left hemiparesis. While in the hospital, he developed congestive heart failure and required an indwelling catheter to monitor his intake and output. Over the next several days, his neurologic and cardiac status stabilized and he was transferred to the nursing home for rehabilitation with the indwelling catheter still in place. Although apraxic and needing total assistance in toileting, his indwelling catheter was removed. Following catheter removal, he remained incontinent with residual volumes greater than 300 cc for three weeks, and was sent for urologie evaluation. Cystoscopy and urodynamic studies revealed an obstructing prostate gland, a trabeculated bladder, and detrusor hyperreflexia. Due to his compromised cardiovascular status, prostatectomy involved a substantial risk. An indwelling catheter was reinserted, with a plan to re-evaluate the patient should complications (eg, frequent symptomatic urinary tract infections) develop.
EXAMPLE OF A BLADDER RETRAINING PROTOCOL
Incorporating a postcatheter retraining protocol into an institution's incontinence management programs will discourage the use of chronic indwelling catheters. Aside from the relatively few patients needing chronic catheterization, indwelling catheterization will take its place as a temporary measure in the control of incontinence. As individual environments within the healthcare system adapt postcatheter bladder retraining protocols to their settings, modifications will be necessary. Once implemented, whether in an acute or long-term care environment, experience will lead to long- and short-term goal setting that should further enhance the success of the programs.21
Inservice educational sessions, educational materials, and task forces can be used to teach the method. However, understanding the value of freeing a patient from catheter dependence is the prime element in any successful program. Cooperation among nurses, nurses aides, and physicians in a team effort is the key ingrethent to success. Well-designed studies should be encouraged that will document the efficacy of such programs.6
- 1. Warren JW, Muncie HL, Berquist EJ, et al: Sequelae and management of urinary infection in the patient requiring chronic catheterization. J Urol 1981; 125:1-7.
- 2. Ouslander JG, Fowler E: Incontinence in VA nursing home care units. J Am Geriatr Soc 1985; 33:33-40.
- 3. MarronKR,FiUitH,PeskowiteM,etai.The nonuse of urethral catheterization in the management of urinary incontinence in the teaching nursing home. J Am Geriatr Soc 1983; 31:278-281.
- 4. Kunin CM: Detection, Prevention and Management cf Urinary Tract Infections. Philadelphia, Lea & Febiger, 1979.
- 5. Jewett MAS, Fernie GR, Holliday PJ, et al: Urinary dysfunction in a geriatric long-term care population: Prevalence and patterns. J Am Geriatr Soc 1981; 29:211-214.
- 6. Ouslander JG, Uman GW: Urinary incontinence: Opportunities for research, education and improvements in medical care in the nursing home setting, in Schneider E (ed): The Teaching Nursing Home - A New Approach to Geriatric Research and Medical Care. New York, Raven Press, 1985.
- 7. Ouslander JG, Kane RL, Abrass IB: Urinary incontinence in elderly nursing home patients. JAMA 1982; 248:1194-1198.
- 8. Sier H, Ouslander JG, Orzeck S: Urinary incontinence in an acutely hospitalized geriatric population. Gerontologist (special issue), 1985; 25:137.
- 9. Kristiansen P, Fompeius R, Wadstrom LB: Long-term urethral catheter drainage and bladder capacity. Neurology and Urodynamics 1983; 2:135-143.
- 10. Ouslander JG, Kane RL: The costs of urinary incontinence in nursing homes. Med Care 1984; 22:69-79.
- 11. Resnick NM, Yalta SB: Management of urinary incontinence in the elderly. N Engl J Med 1985; 313:800-805.
- 12. Williams ME, Pannili PC: Urinary incontinence in the elderly. Ann Intern Med 1982; 97:895-907.
- 13. Hadley F: Bladder Training and Related Therapies. Prepared for the National Institute on Aging's workshop on bladder training. Washington, DC, April, 1983.
- 14. Pollock DD, Liberman RP: Behavior therapy of incontinence in demented inpatients. Geromologisl 1974; 2:488-491.
- 15. Sogbein S, Awad SA: Behavioral treatment of urinary incontinence in geriatric patients. California Medical Association Journal 1982; 127:863-864.
- 16. Long ML: Incontinence: Defining the nursing role. J Gerontol Nurs 1985; 11:30-41.
- 17. Johnson JH: Rehabilitative aspects of neurologic bladder dysfunction. Nurs Clin North Am 1980; 15:293-307.
- 18. Schnelle JF, Traughber B, Morgan DB, et al: Management of geriatric incontinence in nursing homes. J Appi Behav Anal 1983; 16:235-241.
- 19. Williamson ML: Reducing post-catheterization bladder dysfunction by reconditioning. Nurs Res 1982; 31:28-30.
- 20. Ouslander JG, Uman GC, Urman HN: Development and testing of an incontinence monitoring record. J Am Geriatr Soc, to be published.
- 21. Igou JF: Maintaining nursing staff motivation to implement a bladder rehabilitation program through training and follow-up. Science and Medicine, to be published.
- 22. Castleden CM, Duffin HM: Guidelines for controlling urinary incontinence without drugs or catheters. Age Ageing 1981; 10:186-190.
KEY FEATURES OF THREE BLADDER TRAINING PROGRAMS
EXAMPLE OF A BLADDER RETRAINING PROTOCOL