Journal of Gerontological Nursing

Assessment of Urinary Incontinence

Cathy Penn, RN, MA, CRRN; Deborah Lekan-Rutledge, MSN, RN, C, CCCN; Angela Marner Joers, MA, RN; Jacqueline M Stolley, MA, RNC; Natalie Vickrey Amhof, BSN, RNC, CETN

Abstract

A bladder diary is vital in recording the patient's day-to-day bladder habits (McDowell, 1994). The bladder diary records diurnal and nocturnal patterns of voiding, fluid intake, and circumstances associated with UI. Bladder diaries can be more reliable than self-report of symptoms, as people may overestimate or underestimate the magnitude of the problem. Usually, a bladder diary is recorded for 3 to 7 days. Functional and maximal bladder capacity may be determined from the bladder diary. An example of a bladder diary is provided in the Figure.

Medication review determines the extent to which medications adversely affect continence. Categories of drugs that are associated with lower urinary tract dysfunction include diuretics, anticholinergic, alphaadrenergic agonists, beta-adrenergic agonists, alpha agonists, calcium channel blocks, and CS depressants. It is important to note drugs with anticholinergic properties which can precipitate urinary retention, constipation, blurred vision, dry mouth, and dimmed sensorium and confusion, all of which can be very debilitating in the elderly.

Physical Exam

Abdominal exam assesses for peristalsis, masses, bladder distension, and full or impacted bowel. In women, observation of the external genitalia and vaginal introitis assesses for local inflammation due to dermatitis from urine, bacterial or yeast infection, vulgar and vaginal atrophy and pallor, and evidence of weak pelvic support. Pelvic support abnormalities such as cystocele, rectocele, uterine descent and prolapse may be observed by asking the patient to bear down or cough vigorously (valsalva maneuver) and noting protrusion of organs. Advanced practice nurses may further assess for pelvic abnormalities using a vaginal speculum to visualize the and anterior and posterior wall of the vagina for organ descent. In settings where a speculum may not be available as in the home or nursing home setting, a digital exam may palpate organ descent while the patient is bearing down (McDowell, 1994).

The stress maneuver is performed by asking the patient to cough while observing the urethra for urine loss. This maneuver must be done with a full bladder (of at least 200 ml urine) for reliable results. The maneuver is performed in the lithotomy position, and if the test is negative, repeated in the standing position, placing a tissue or absorbent pad beneath the urethra. A short spurt of urine suggests stress urinary incontinence due to ineffective pelvic muscle response, whereas a large gush of urine suggests urge incontinence due to inappropriate detrusor contraction. Women who have observable pelvic prolapse beyond the introitus or those who experience symptoms of pelvic descent need referral to a gynecologist (Wyman, 1991).

The pelvic muscle is assessed by digital exam with one or two gloved, lubricated fingers, for mass (thin, moderate, thick), ribbing (smooth or ribbed), symmetry, and strength and duration of contraction (Brink, Sampsell, Wells, Diokno, & Gillis, 1989). Another clinical rating scale mat assesses muscle strength is rated on a scale of O to 5, with O denoting no palpable muscle contraction, 1 denoting a flicker which is barely detectable, to 5 denoting a strong contraction (Wyman, 1991). Assessment of pelvic muscle contraction is important to validate the patient's ability to isolate and contract the muscle appropriately and whether pelvic muscle exercises/strengthening would be an appropriate intervention.

The rectal exam begins with inspection of the perianal skin for lesions, varicosities, and skin alterations. Integrity of anal sphincter tone, sensation, and contraction is assessed. Fecal impaction should be ruled out. In males, examination of pelvic muscle strength may be elicited by asking the patient to contract the anal sphincter around the examiner's finger. This examination is particularly appropriate for males experiencing post-prostatectomy UI. Finally, male genitalia are inspected to detect abnormalities of the foreakin, glans penis, and…

Many elders as well as health care professionals Ido not view incontinence as abnormal but as a normal part of the aging process (Colling, 1988; Dowd, 1991; Goldstein, Hawthorne, Engberg, McDowell, & Burgio, 1992; Reilly & Karlowicz, 1990). Urinary incontinence (UI) has been viewed as a nuisance to be managed rather than as a symptom of an underlying pathology needing investigation (Newman & Burns, 1994; Williams, Wallhagen, & Dowling, 1993).In order to change views of the normalcy of UI in the elderly, nurses must be educated about the dimensions of UI. Accurate assessment and diagnosis determine the success of treatment. As nurses experience more success in restoring continence, attitudinal barriers will also lessen. Health professionals, especially nurses, are a key source of understanding, advice and treatment for those with UI (Newman & Burns, 1994). Sensitivity toward the emotional distress frequently associated with UI is imperative, because many patients are exposed to pessimistic attitudes toward resolution of UI by their health care providers.

NORMALAAECHANISMSFOR MAINTAININGCONTINENCE

There are two distinct phases of lower urinary tract function. The first is the bladder filling phase and the storage of urine, and the second is the bladder emptying phase. Normal function of the lower urinary tract is dependent upon the following:

1. the anatomic integrity of the bladder and urethra;

2. an intact neurologic system that provides voluntary and coordinated control of voiding;

3. the pattern of urine production;

4. the desire and physical capability of the person to perform the activities associated with normal toileting (Staskin, 1986).

Functionally, the bladder and urethra act as a single unit in the process of storing and emptying urine. The storage phase is dependent upon a stable detrusor (bladder) muscle which inhibits contractions as the bladder distends to accommodate increasing volumes of urine. In addition, the storage phase requires a competent "sphincter mechanism" of the urethra which is responsible for maintaining increased urethral pressure and closure (Wyman, 1991). Spinal reflex contraction impulses are continually generated between the spinal column and the bladder. Continuous inhibitory signals from the brain (in the pons) normally prevent these signals from causing bladder contractions. Voiding is mediated by the sacral micturition center (S2-S4) and is controlled voluntarily by complex interactions among cortical areas (frontal cortex), subcortical areas (thalamus, hypothalamus, basal ganglia, and limbic system), and brain stem (mesencephalic-pontine-medullary reticular formation) (Benson & Walters, 1993).

During bladder filling, there is little or no increase in intravesicular pressure as smooth muscle and connective tissue in the bladder wall stretch and accommodate increased urine volume. Detrusor muscle contractility is probably inhibited by activation of a spinal sympathetic reflex, which results in bladder relaxation. Approximately 150 to 250 ml of urine can be stored before bladder pressure begins to increase and the urge to void is felt (Wyman, 1991). As bladder filling approaches functional bladder capacity (the volume at which one would usually become uncomfortable and seek toileting facilities), mechanoreceptors in the bladder wall are stimulated and an urge to void is felt. Bladder outlet resistance increases by reflex stimulation of alpha-adrenergic receptors within the smooth muscle of the bladder neck and proximal urethra. As long as the urethral pressure is greater than the intravesical pressure, continence is maintained.

Normal voiding is a voluntary act coordinated through central and autonomie nervous systems to first facilitate relaxation of the urethra, shortly followed by a rise in intravesicular pressure secondary to sustained contraction of the bladder. The bladder neck descends and funnels to allow urine to flow until the bladder is emptied. With termination of voiding, the striated muscles of the urethra and pelvic floor contract to elevate the bladder base and increase intraurethral pressure, and inhibit further detrusor contractions (Benson & Walters, 1993).

PREDISPOSING AND AGE-RELATED FAQORS TO URINARY INCONTINENCE

Predisposing and age-related factors associated with increased risk for urinary incontinence are summarized below.

Increased Residual Urine

Any post-void residual (PVR) urine volume predisposes to both infection and incontinence. APVR of less than 50 mL is considered adequate bladder emptying and over 200 mL is considered abnormal (UI Guideline Panel, 1992). Residual urine may be due to poor bladder contractility or outlet resistance.

Diminished Bladder Capacity

Normal aging contributes to a reduction in muscle mass of the bladder wall, decreased elasticity and compliance of the bladder wall, and increased tone. Bladder capacity may decrease from 500 to 600 ml in normal adults to 250 to 300 ml in older adults. Decreased bladder capacity may contribute to frequency and nocturia.

Detrusor Instability

Normal age-related changes in the cerebral cortex and spinal reflex arc may predispose to uninhibited bladder contractions. These contractions often occur at small bladder volumes and may be inappropriately strong given the small urine volume. Although not clearly understood, individuals with detrusor instability have a marked decrease in neuropeptides which affects relaxation and regulation of smooth muscle in the bladder. It has been proposed that deficiency of this substance may be key to the development of detrusor instability (Karram, 1993). Older persons often report decreased "holding time/' or the time between when a strong urge is felt, and when they absolutely must void at the risk of losing urine (Palmer, 1986).

Benign Prostaric Hyperplasia

Benign prostatic hyperplasia, a non-cancerous enlargement of the prostate gland, is a normal age-related development in men, with the prevalence of greater than 50% in men greater than 60 years of age. By age 85, Ute prevalence is approximately 90% (McConnell et al., 1994). Prostatic hyperplasia increases urethral resistance and contributes to increased residual urine volume. Over time, prolonged obstruction chronic overdistention can lead to loss of bladder tone. Symptoms of outlet obstruction include difficulty starting the urine stream, weak or intermittent stream, hesitancy, prolonged voiding, postvoid dribbling, and a sensation of incomplete emptying.

Excessive Nocturnal Urine Excretion

With increasing age, the kidneys become less efficient in concentrating and excreting urine and may produce more urine at night than during the day. Excessive urine production at night may be related to diabetes mellitus, diabetes insidious, congestive heart failure, venous stasis, and to deficits in anti-diuretic hormone production. Reduction in bladder capacity may further exacerbate this situation. Sleep-related problems may predispose to nocturia, including sleep disorders, pain, dyspnea, depression, caffeine, alcohol, and medications (Resnick, 1990). Nocturia greater than twice per night is considered abnormal in the elderly (Palmer, 1986).

Obesity

Obesity, defined as greater than 20% over the average weight, for height and age, is associated with increased risk for UI and is more common in women who are incontinent (Dwyer, Lee, & Hay, 1988). Excessive body weight weakens pelvic muscle supports.

Chronic Constipation

Chronic constipation adversely affects urologie function, A distended rectum can compress the bladder neck and contribute to urinary retention and urinary tract infection. Frequent straining during bowel evacuations can injure pelvic muscles and nerves through traumatic overstretching and muscle ischemia.

Underhydration

Contrary to popular belief, reduction of fluid intake does not improve UI. Inadequate fluid intake may lead to urgency and frequency since concentrated urine is irritating to the bladder. Frequent urination has a deconditioning effect on the bladder, thereby shrinking bladder capacity. Concentrated urine also facilitates bacterial proliferation and increases risk for urinary tract infections. Even with good hygiene practices, concentrated urine creates a strong odor. Many elderly, particularly those in long-term care, are at increased risk for underhydration (Colling, Owen, & McCreedy, 1994)

Smoking

Active ingrethents in cigarettes, including tars, are bladder irritants, which may contribute to urgency, frequency, and urge incontinence. Smokers tend to develop chronic coughs, which may put undue strain on pelvic muscles thus provoking stress incontinence (Bump & McClish, 1994). Carcinogens in cigarettes may also increase risk for bladder cancer.

Childbirth

A number of factors have linked childbirth and high risk of UI, including parity, high birthweight, difficult delivery with prolonged stage 2 or use of forceps during delivery, and childbirth injury related to severe lacerations or tears. Vaginal delivery may lead to weakened, damaged, or denervated pelvic muscles and pelvic fasciai supports

Estrogen Dedine

The vagina, urethra, The vagina, urethra, and trigone uscle have similar epit iuscle have similar epithelial linings ch in estrogen receptors. When fully estrogenized, the intraurethral walls are soft, moist, and interdigitated to form a watertight seal. With declining hormone levels, the walls of the urethra become harder, the folds become less pronounced, and mucous production decreases, resulting in less efficient closure (Palmer, 1994). Such changes contribute to urethritis, trigonitis, atrophie vaginitis, and thinning and weakening of endopelvic fascia and pelvic muscles. Irritative voiding symptoms present as frequency, urgency, dysuria, and urge incontinence.

Cognitive Decline

Reduced cognition in the older person with dementia or transient or acute confusion will reduce awareness of the sensation of bladder filling and the need to void. Acute confusion may be due to an infection, fluid and electrolyte imbalance, new medication, pain, fecal impaction, and sleep disruption (Palmer, 1994). Dementia is often associated with apraxia, the loss of the ability to maintain certain self-care skills including toileting. Dementia and mobility impairments may contribute to functional incontinence. Nursing initiatives to maintain self-care and mobility and improve the physical environment may promote continence in impaired elderly (Jirovec & Wells, 1990).

Dysmobility

Factors which inhibit mobility, including musculoskeletal problems (stiffness, pain, rigidity, decreased range, instability, etc.), neurologic problems (weakness, paralysis, reduced sensation), easy fatigueability and poor endurance, exertional dyspnea, frailty, apathy, etc., predisposes to UI.

TRANSIENT AND PERSISTENT INCONnNENCE

Determining the timing and circumstances associated with the onset of UI helps focus diagnostic and treatment interventions appropriately. Transient incontinence is characterized by a fairly sudden or recent onset of symptoms. The temporary episodes of Ul are reversible when the underlying cause is treated. Underlying causes of transient UI are summarized in the Table. It is believed that approximately 30% of all cases of urinary incontinence in older people are transient. If not appropriately treated, transient UI will not reverse itself and will persist. Persistent UI is determined when transient causes are either ruled out or therapeutic trials of treatment have not successfully reversed the UI. Persistent UI compels more in-depth evaluation. Persistent UI is classified based upon assessment of lower urinary tract function of filling, storing and emptying urine. Evaluation should carefully look at both the storage and emptying phase, including symptom profile and history, physical examination, bladder function studies and in some instances, urodynamic studies.

TYPES OF URINARY INCONTINENCE

It is clinically useful to differentiate four types of persistent UI based on the AHCPR Clinical Practice Guideline (UI Guideline Panel, 1992): stress, urge, mixed, and overflow UI. Nongenitourinary UI, termed functional UI, describes UI due to cognitive and physical impairments, environmental barriers, pharmacologie and iatrogenic etiologies. Determining the type of UI is important in identifying the most appropriate treatment (UI Guideline Panel, 1992).

Stress Ui is characterized by leakage of urine during physical activity (such as walking, exercising, bending, lifting) or periods of increased intraabdominal pressure (such as coughing, laughing, sneezing). Periurethral muscles fail to maintain urethral closure and urine escapes. Urine loss is usually in small amounts, a few drops to a few teaspoons. Nocturia or enuresis is not present. Stress UI is more common in women due to childbirth and hormone-related factors, but may be found in men after prostate surgery.

Urge UIf or detrusor instability, involves leakage of urine that is associated with a sudden, strong, uncontrollable urge to void, and the inability to delay voiding. Urge UI is due to abnormal bladder storage, detrusor overactivity, and uncontrolled bladder contractions. Characteristics include urgency, frequency, urge UI, and nocturia. Detrusor overactivity that has neurologic origins, such as due to Parkinson's disease, cerebrovascular accident, multiple sclerosis, and spinal cord injury, is termed detrusor hyperreflexia. In patients without neurologic disease, detrusor instability and urge UI is idiopathic. This type of UI is the most common type in older adults. A subset of older persons with detrusor instability may also have documented urine retention due to ineffective or poor bladder contractility. This condition is termed detrusor instability with impaired contractility (DHIC) (Resnick & Valla, 1987). These patients may experience recurrent urinary tract infection or acute urinary retention secondary to anticholinergic drugs.

Table

TABLECouses of Transient Incontinence

TABLE

Couses of Transient Incontinence

Mixed UI is characterized by the presentation of both stress and urge UI simultaneously. Clinical presentation may reveal primary and secondary symptoms whereby UI is either most often associated with physical activity or with uncontrollable bladder urges. Since bladder activity and urethra! sphincter function are inter-related in maintaining continence, mixed UI likely involves a continuum of interrelationships contributing to a mixed symptom pattern (Wall, Norton, & DeLancey, 1993).

Overflow UI is leakage of urine without the urge to void, resulting from a distended bladder. Bladder retention may be due to outlet obstruction or impaired contractility. The bladder may be underactive because of drugs, fecal impaction, neurologic conditions such as lower spinal cord injury or diabetic neuropathy, or following pelvic surgery. Obstruction may be due to prostatic hyperplasia in men, cystocele and pelvic prolapse in women.

Functional UI is urine loss due to factors outside of the lower urinary tract, such as physical mobility or cognitive deficits which impair one's ability to perceive the need to toilet and be motivated to do so, to behave in a manner that is socially appropriate, and to physically be able to undress and maneuver oneself. Medications that adversely affect cognitive function and sensorium particularly contribute to functional UI. Environmental barriers that impede access to toilets or when toilets are unavailable also contribute to functional UI.

COMPREHENSIVE NURSING ASSESSMENT Of Ul

The purpose of the basic evaluation of UI is to detect and confirm UI objectively, identify factors that may be contributing to or precipitating UI, or that result from UI, and identify patients who need further specialized evaluation before any therapeutic interventions are initiated (UI Guideline Panel, 1992; Wyman, 1991). Nursing assessment to conduct basic evaluation of patients who present with UI and other voiding symptoms can readily uncover potentially treatable causes and contributing factors to UI. In complex patients with neurologic, urogynecologic, or urologie disorders, they may be referred to a specialist for more comprehensive evaluation and possible advanced urodynamic testing (Wyman, 1991). The basic nursing assessment of UI includes history, a bladder diary, medication review, physical exam, functional assessment, and additional tests such as urinalysis and culture and post-void residual measurement. The Rapid Assessment of Urinary Elimination, illustrated in the Figure, addresses each of these domains in a brief one-page assessment. Further assessment by the advanced practice nurse or continence nurse specialist may include simple cystometry, and urodynamic studies.

History

The onset, timing, and frequency of UI is important to determine. Medical and surgical history significant for UI is recorded. In particular, neurologic, metabolic, musculoskeletal, gynecologic and urologie conditions are determined. A UI symptom profile assesses for frequency, urgency, nocturia, dysuria, nocturnal enuresis, or voiding dysfunction (hesitancy, straining, postvoid dribbling, intermittence). Lifestyle risk factors including obesity, parity, poor fluid intake, chronic constipation or fecal incontinence, and tobacco, alcohol and caffeine use are considered. Previous treatment and outcomes should be noted. Psychological impact of UI is assessed by asking about how UI symptoms have affected lifestyle and quality of life.

Figure: A brief one-page assessment.

Figure: A brief one-page assessment.

A bladder diary is vital in recording the patient's day-to-day bladder habits (McDowell, 1994). The bladder diary records diurnal and nocturnal patterns of voiding, fluid intake, and circumstances associated with UI. Bladder diaries can be more reliable than self-report of symptoms, as people may overestimate or underestimate the magnitude of the problem. Usually, a bladder diary is recorded for 3 to 7 days. Functional and maximal bladder capacity may be determined from the bladder diary. An example of a bladder diary is provided in the Figure.

Medication review determines the extent to which medications adversely affect continence. Categories of drugs that are associated with lower urinary tract dysfunction include diuretics, anticholinergic, alphaadrenergic agonists, beta-adrenergic agonists, alpha agonists, calcium channel blocks, and CS depressants. It is important to note drugs with anticholinergic properties which can precipitate urinary retention, constipation, blurred vision, dry mouth, and dimmed sensorium and confusion, all of which can be very debilitating in the elderly.

Physical Exam

Abdominal exam assesses for peristalsis, masses, bladder distension, and full or impacted bowel. In women, observation of the external genitalia and vaginal introitis assesses for local inflammation due to dermatitis from urine, bacterial or yeast infection, vulgar and vaginal atrophy and pallor, and evidence of weak pelvic support. Pelvic support abnormalities such as cystocele, rectocele, uterine descent and prolapse may be observed by asking the patient to bear down or cough vigorously (valsalva maneuver) and noting protrusion of organs. Advanced practice nurses may further assess for pelvic abnormalities using a vaginal speculum to visualize the and anterior and posterior wall of the vagina for organ descent. In settings where a speculum may not be available as in the home or nursing home setting, a digital exam may palpate organ descent while the patient is bearing down (McDowell, 1994).

The stress maneuver is performed by asking the patient to cough while observing the urethra for urine loss. This maneuver must be done with a full bladder (of at least 200 ml urine) for reliable results. The maneuver is performed in the lithotomy position, and if the test is negative, repeated in the standing position, placing a tissue or absorbent pad beneath the urethra. A short spurt of urine suggests stress urinary incontinence due to ineffective pelvic muscle response, whereas a large gush of urine suggests urge incontinence due to inappropriate detrusor contraction. Women who have observable pelvic prolapse beyond the introitus or those who experience symptoms of pelvic descent need referral to a gynecologist (Wyman, 1991).

The pelvic muscle is assessed by digital exam with one or two gloved, lubricated fingers, for mass (thin, moderate, thick), ribbing (smooth or ribbed), symmetry, and strength and duration of contraction (Brink, Sampsell, Wells, Diokno, & Gillis, 1989). Another clinical rating scale mat assesses muscle strength is rated on a scale of O to 5, with O denoting no palpable muscle contraction, 1 denoting a flicker which is barely detectable, to 5 denoting a strong contraction (Wyman, 1991). Assessment of pelvic muscle contraction is important to validate the patient's ability to isolate and contract the muscle appropriately and whether pelvic muscle exercises/strengthening would be an appropriate intervention.

The rectal exam begins with inspection of the perianal skin for lesions, varicosities, and skin alterations. Integrity of anal sphincter tone, sensation, and contraction is assessed. Fecal impaction should be ruled out. In males, examination of pelvic muscle strength may be elicited by asking the patient to contract the anal sphincter around the examiner's finger. This examination is particularly appropriate for males experiencing post-prostatectomy UI. Finally, male genitalia are inspected to detect abnormalities of the foreakin, glans penis, and perinea! skin.

Functional status assessment addresses the older person's access to a toilet or toilet substitute, the time it takes to toilet and the skills needed to toilet successfully (ability to transfer, appropriate toilet height, dexterity, clothing that is difficult to undo, etc.). Clothing that is cumbersome or multi-layered (girdles, garters, belts, pantyhose, slips) may unnecessarily complicate toileting. The individual's ability to cognitiveIy attend to toileting needs and to anticipate needs should also be considered. Formal cognitive testing should be included in the basic evaluation of the older patient to estabish the individual's ability to comprehend verbal and written instructions and to learn new self-care activities and continence interventions (McDowell, 1994). The Folstein Mini-Mental State Examination (MMSE) is a clinically useful standardized test commonly used in vaseline assessment (Folstein, Folstein, & McHugh, 1987).

Fjivironmental assessment identifies the location and accessibility of toilets, availability of toilet substitutes (urinals, commodes, devices), distance traveled to the toilet, cleanliness and safety in the toileting area, adaptive toilet equipment such as grab bars and raised seats. The patient's actual ability to use a toilet or toilet substitute is important to observe (Palmer, 1994). The availability, capability, and willingness of caregivers to assist the individual to toilet (if needed) should also be assessed. Since impaired mobility is considered a risk factor for incontinence, appropriate measures to maintain and promote mobility should be addressed, including assistive devices such as walkers and canes, and referral to physical or occupational therapy for rehabilitation (Palmer, 1994). Proper shoes, foot care, and uncluttered walkways should also be considered. Improvement in mobility may translate into improvement in continence (Jirovec, 1991).

A quick diagnostic screen to evaluate a number of urologie parameters involves obtaining a clean catch urine specimen and testing it with an esterase dipstick to evaluate for nitrite and WBC as indicators of urinary tract infection (UTI), specific gravity as an indicator of fluid hydration, and RBC/hematuria as an indicator for an infectious, and irritative problem such as UTI, stones, or tumor. If the patient experiences recurrent UTIs, pH may also be useful as a baseline for urine acidification treatment with vitamin C. Proteinuria is associated with kidney disease. One or more post-void residual (PVR) determinations is also helpful to rule out a bladder emptying problem, particularly in neurologically-affected patients. The PVR may be measured directly via urethral catheterization or indirectly by using a bedside bladder ultrasound instrument. Referral for further medical evaluation may be indicated if the PVR is greater than 100 mL (Resnick, 1990). Urine cytology should be considered to screen for bladder carcinoma if the onset of UI is recent and associated with severe irritative symptoms, if there is suprapubic pain or if the patient is at high risk (smoking history is particularly relevant) (Resnick, 1990). Reviewing labwork such as the BUN and creatinine provides information about adequate renal function. Serum electrolyte levels should be evaluated in patients demonstrating excessive urine volume.

Further evaluation of bladder function may be performed by the advanced practice nurse or continence nurse specialist if the continence diagnosis remains uncertain, if neurological disorders are suspected, or if a therapeutic trial of behavioral or pharmacologie treatment has failed (Wyman, 1991). Further testing may include simple cystometry and urodynamics including complex cystometry and uroflowmetry (Lekan-Rutledge, 1992a; Wyman, 1991). These studies evaluate bladder filling and emptying and the variables that provoke UI. Simple cystometry is performed at the bedside using a standard urinary catheter. After the patient voids, a post-void residual urine measurement is taken and the catheter is left in the bladder. Bladder filling with sterile water is accomplished by using a toomey syringe with the plunger removed and instilling fluid at a rate of approximately 50 cc per minute. Estimation of the volume infused when the patient reports the first bladder urge, a feeling of bladder fullness, and maximal bladder capacity is recorded. Provocative maneuvers including coughing or bearing down with a full bladder are performed to precipitate UI symptoms. For more detailed discussion about the procedure, additional information is available (LekanRutledge, 1992a; Ouslander, Leach, & Staskin, 1989; Wyman, 1991). Uroflowmetry is the evaluation of bladder emptying to discern obstructive voiding symptoms. This may be performed with specialized electronic equipment however, the nurse can assess the quality of the urine stream by listening while the patient voids, noting hesitancy, intermittency, weak stream, and prolonged voiding. Using a stopwatch, the start and finish of the urine stream is measured and compared to standardized flow rates. Voiding time will vary according to the volume voided, however, even large bladder volumes should be emptied within 30 to 60 seconds (Gray, 1990). Complex cystometry utilized specialized equipment to measure various bladder and urethra parameters simultaneously to provide a profile of bladder function and correlates associated with UI (Gray, 1990).

The clinical impression is developed based on a synthesis of clinical information yielded. A working diagnosis of stress, urge, mixed, overflow, or functional UI is determined and a therapeutic trial of behavioral and /or pharmacologie treatment initiated to address causes and contributing factors. Findings that warrant further medical followup include hematuria without infection, pelvic prolapse, recurrent urinary tract infection, pain or severe irritative symptoms, obstructive voiding symptoms, abnormal labwork, and elevated post-void residual measurements (UI Guideline Panel, 1992).

ASSESSMENTTOOLS

Specialists in continence care have recognized the need to guide nonspecialists through accurate assessment. Through review of the literature, a variety of assessment aids were found. These include (a) lengthy descriptions of nursing assessments for incontinence (Creason, Burgener, & Farrand, 1992; Gray, 1990; Irvine, 1991; Jirovec, Brink, & WeUs, 1988), (b) simple voiding records (Autry, Lauzon, & Holliday, 1984; Hughes & Anderson, 1992; Miller, 1990; Ouslander, Urman, & Uman, 1986; UI Guideline Panel, 1992), and (c) "assessment forms" which help guide a thorough assessment (Doughty, 1991; Specht, Tunink, Maas, & Bulechek, 1991). These tools are helpful in collecting appropriate data, but do not directly assist the user in coining to specific UI diagnoses.Three assessment tools developed to lead the nurse to specific UI nursing diagnoses will be reviewed here. They are (1) the Perm Continence Clinic Assessment Form (Penn, unpublished); (2) the LekanRutledge Urinary Incontinence Nursing Assessment Form (UINAF) (Lekan-Rutledge, 1992b); and (3) Lekan-Rutledge Rapid Assessment of Urinary Incontinence (Figure). AU three forms include Omnibus Budget Reconciliation Act (OBRA)mandated assessment for urinary incontinence and incorporate recommendations from the Agency for Health Care Policy and Research (AHCPR) Clinical Guidelines for UI.

The Penn Continence Clinic Assessment Form

The Penn Continence Clinic Assessment Form was initially designed to assist non-specialist nurses in advancing their UI assessment and intervention skills while establishing a continence clinic in a long-term care facility. It is highly structured to guide nurses through comprehensive assessment, determination of the type(s) of UI, initiation of appropriate referrals, and selection of interventions based on the underlying etiologies of UI.

The Penn Continence Clinic Assessment Form allows the user to identify more than one type of UI, an important feature for a population which frequently experiences "mixed" types of UI. It includes assessment for reflex UI, a type of Ul difficult for non-specialist nurses to understand and diagnose. The comprehensive approach to data collection provides an opportunity to improve other conditions associated with UI such as altered skin integrity, altered bowel elimination, and ineffective individual coping.

Average completion time of this comprehensive assessment is 95 minutes, limiting its usefulness in many clinical settings. It is helpful in teaching nurses how to complete a comprehensive assessment and accurate diagnosis of UI. It may be useful for research projects which require accurate diagnosis, before assigning subjects to clinical trials of LJI interventions. A 95% interrater reliability for the tool, which included 150 items, was documented (Perm, 1990).

Lekan-Ruriedge Urinary Incontinence Nursing Assessment Form

The Lekan-Rutledge Urinary Incontinence Nursing Assessment Form (UINAF) (Lekan-Rutledge, 1992b) was initially designed for use in a demonstration project to determine effectiveness of clinical and staff management strategies for implementing prompted voiding in a long-term care nursing facility. The UINAF guides the nurse to broadly assess and determine a probable incontinence diagnosis. The twopage assessment form is followed by a one-page care plan. The UINAF identifies medical conditions, medications, functional status parameters, and risk factors that are associated with UI. Additional physical assessment maneuvers including pelvic exam and simple cystometry may be conducted by advanced practice nurses or nurses with specialized training as a continence nurse specialist. Continence interventions are listed in a checklist to facilitate planning appropriate interventions for each type of UI.

Lekan-Ruriedge Rapid Assessment of Urinary Elimination

The Lekan-Rutledge Rapid Assessment of Urinary Elimination (Lekan-Rutledge, unpublished) is a one-page form for use by staff nurses to complete a brief screening of the patient's history, physical status, functional status, and medication regime (Figure). The assessment targets iatrogenic and transient causes of UI. Early identification and intervention would be followed by more detailed evaluation when appropriate. This tool may be useful in acute care settings where length of patient stays are short, and the opportunity for in-depth assessment and intervention is limited or inappropriate because of acute medical or surgical events. In other settings, this tool may be used as the first step in screening. Follow-up contact in the community with urinary continence specialists in nursing, gynecology, urology, geriatrics and home health nursing is critical.

Validity and reliability of these three UI assessment tools have not yet been established. The tools have been reviewed and used clinically by gerontological clinical nurses and nurses in long-term care and acute care settings. Further testing is necessary to establish acceptable psychometric properties. Slight modification of each tool may be necessary to adapt to the setting of care, the patient population, the purpose of the assessment, and the time available for conducting the assessment.

SUMMARY

The authors present a brief overview of the problem and significance of UI, stressing the importance of accurate and timely nursing assessment. Three UI assessment tools are described for use by nonspecialist registered nurses and advanced practice nurses in various health care settings.* It is recommended that others using UI assessment tools consider validating those tools and publishing the results and tools in the literature. Sharing of such information is important for the clinical advancement in the area of UI.

The high prevalence and serious problem of underreporting of UI must be addressed by nurses in all practice settings. In the past, nursing practice toward incontinence has focused on urine containment and skin protection rather than taking a proactive position toward treatmentoriented, therapeutic care as articulated in the AHCPR Clinical Practice Guideline on UI (Colling, 1994). Efforts directed at early identification, appropriate assessment and treatment, and linkage to community agencies should be initiated by the nurse. It is also the nurse's responsibility to educate the patient about the prevention and treatment of UI with various modalities including behavioral therapies.

REFERENCES

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