Urinary Elimination: Urinary Incontinence

URINARY INCONTINENCE

Involuntary loss of urine from the bladder

    Causes

·        Urinary Tract Infections

·        Urethritis

·        Pregnancy

·        Hypercalcemia

·        Volume Overload

·        Delirium

·        Restricted Mobility

·        Psychologic Causes

There are two categories

Ø Acute

Ø Chronic

Acute:

Many factors can contribute to acute or reversible incontinence, including polyuria, exposure to irritants, infection, urinary retention, use of pharmaceuticals, stool impaction or constipation, atrophic urethritis or vaginitis, restricted mobility or dexterity, psychologic conditions, and delirium or acute confused state.

Some of these factors are readily reversible with a lessening of symptoms.

Chronic:

Types

·        Functional

·        Overflow

·        Reflex

·        Stress

·        Urge

Functional:

·        Sudden, involuntary loss of small amounts (<50ml) of urine that accompanies a sudden increase intra-abdominal pressure

·        Ex: of activities that increase intra-abdominal pressure

---- Coughing, sneezing, laughing, lifting and jumping

·        Factors associated:

ü Weakened pelvic floor muscles (child birth)

ü High intra-abdominal pressure (obesity, pregnancy)

ü Damage to the bladder neck

ü Side effects of medications

ü Direct trauma from a fractured pelvis or genito urinary surgery

Urge Incontinence:

ü Involuntary loss of urine after strong feeling of need to urinate

ü Unable to perceive a full bladder and to hold urine until reaching the bathroom

ü Frequency, Dysuria, Nocturia commonly accompany the Urge Incontinence

            Factors associated Urge Incontinence

·        UTI

·        Use of diuretics

·        Caffeine and alcohol consumption

·        Smoking (nicotine)

·        Increased fluid intake

·        Over distended bladder

Reflex Incontinence

·        Involuntary loss of urine that occurs at somewhat predictable intervals when a specific bladder volume is reached

·        It is seen in clients with:

ü neurological impairments

ü Spinal cord lesion

ü Cerbrovascular accident

ü Brain tumor

·        Bladder emptying occurs at the sacral reflex level because of the impairment of the connection to the cerebrum that allows voluntary inhibition of voiding

Functional Incontinence

·        Inability or unwillingness of a person with normal bladder and sphincter control to reach the bathroom to void

·        Environmental barriers, disorientation, physical limitations may contribute

Total Incontinence

·        Involuntary, unpredictable loss of urine from a non-distended bladder

·        Factors associated:

ü Specific neurologic lesion in the brain or spinal cord

ü Traumatic injury to the genito-urinary area

ü Congenital malformations within the urinary tract or spinal cord

MANAGING URGE INCONTINENCE:

Nursing interventions for clients with urinary incontinence include

(a)              A behavior oriented continence training program that may consist of bladder training, habit training, prompted voiding, pelvic muscle exercises & positive reinforcement      

(b)             Meticulous skin care

(c)              Males: application of external drainage device (condom type catheter device)

Continence (bladder) training:-  A continence training program requires the involvement of the nurse, the client and support people.

A bladder training program may include the following:

Education of the client and support people

Bladder training, which requires that the client postpone voiding, resists or inhibits the sensation of urgency, and void according to a timetable rather than according to the urge to void.

ü  The goals are to gradually lengthen the intervals between urination to correct the client's frequent urination, to stabilize the bladder, and to diminish urgency.

ü  This form of training may be used for clients who have bladder instability and urge incontinence.

ü  Delayed voiding provides larger voided volumes and longer intervals between voiding. Initially, voiding may be encouraged every 2 to 3 hours except during sleep and then every 4 to 6 hours.

ü  The nurse instructs the client to practice deep, slow breathing until the urge diminishes or disappears. This is performed every time the client has a premature urge to void.

Habit training, also referred to as timed voiding or scheduled toileting, attempts to keep clients dry by having them void at regular intervals. With habit training, there is no attempt to motivate the client to delay voiding if the urge occurs. This approach can be effective in children who are experiencing urinary dysfunction.

     Biofeedback therapy in which the child is taught to relax the pelvic floor can also decrease incidents of wetting

     Prompted voiding supplements habit training by encouraging the client to try to use the toilet (prompting) and reminding the client when to void.

PELVIC MUSCLE EXERCISES: Pelvic muscle exercises (PME), or Kegel exercises, help to strengthen pelvic floor muscles and can reduce or eliminate episodes of incontinence. The client can identify the perineal muscles by stopping urination midstream or by tightening the anal sphincter as if to hold a bowel movement.

CLIENT TEACHING:

First, sit or lie in a comfortable, relaxed position. Contract your pelvic muscles whereby you pull your rectum, urethra, and vagina up inside, and hold for a count of 3 to 5 seconds. Then relax the same muscles for a count of 3 to 5 seconds. Initially perform each contraction 10 times, three times daily. Gradually increase the count to a full 10 seconds for both contraction and relaxation

PME can be performed anytime, anywhere, sitting or standing—even when voiding.

MAINTAINING SKIN INTEGRITY:

   Skin that is continually moist becomes macerated (softened). Urine that accumulates on the skin is converted to ammonia, which is very irritating to       the skin.

   Because both skin irritation and maceration predispose the client to skin breakdown and ulceration, the incontinent person requires meticulous skin care.

    To maintain skin integrity wash the perineal area with mild soap and water, dry gently and provide clean dry clothing

APPLYING EXTERNAL URINARY DRAINAGE DEVICES:

The application of a condom or external catheter connected to a urinary drainage system can be used for incontinent males. Use of a condom appliance is preferable to insertion of a retention catheter because the risk of urinary tract infection is minimal.