Managing Urinary Incontinence Post Stroke

Telehealth 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

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

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)

Responses to UI:

Fear embarrassment shame anxiety frustration guilt anger

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

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

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

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

Detrusor musclerelaxes

+Urethral

Sphinctertone

+Pelvic floor

tone

Detrusor musclecontracts

+Urethral

SphincterRelaxes

(Voluntary control)+

Pelvic floorRelaxes

MICTURITION

Detrusor musclerelaxed

+Urethral

Sphinctercontracts

+Pelvic floorcontracts

Detrusor musclerelaxes

+Urethral

Sphinctertone

+Pelvic floor

tone

Bladder fillingBladder filling

First sensationto void

Normal desireto void

Emptying phase

Bla

dd

er p

ress

ure Storage phase

Normal Micturition Cycle

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

CNS control of bladder:

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

CNS control of bladder functioning:

Pontine centre

receives input from the cerebral cortexcoordinates detrusor contraction and

urethral relaxationinhibitory impulses from the pontine

centre allows bladder to store urine

CNS control of bladder functioning:

Sacral Centre

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

Types of incontinence anyone can experience:

Stressurgeoverflowfunctional

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

Urge incontinence:

Loss of urine with a strong unstoppable urge to urinate

S&S: 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”

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

S&S: dribbling, urgency, frequency, hesitancy

Functional Incontinence:

UI that results from barriers that prevent the person from getting to the BR in time

e.g. impaired cognitive functioning (Alzheimer’s), or impaired physical functioning (arthritis)

Stroke & UI: depends on part of brain affected

How strokes affect UI:

FRONTAL STROKEvoluntary control of the external

sphincter but uninhibited bladder contraction

strong urge to void with short/no warning

persistent frequency, nocturia, urge incontinence

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

Hemispheric Stroke:

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

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

Assessment of Urinary Incontinence

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

Incontinence History

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

Fluid intake

How much Restrictions Caffeine alcohol

bowels

Pattern Constipation Diet Laxatives

Medical history:

Stroke Parkinson’s Multiple Sclerosis Diabetes Repeated urinary tract infections Acquired brain injury Dementia

medications

Diuretics Anticholinergics Estrogen Sedatives/hypnotics Antidepressants

Functional ability

Access to bathroom Ambulation

Needs assistance wheelchair

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

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

Conservative treatment all team members can do:

Client/family focusedusing educationbehaviour modificationproblem solving strategies

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

Pelvic muscle exercises (Kegel’s)

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

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

Treatment Medications: Anticholinergics:

Reduce irritability of the bladder larger bladder volumes reduces frequency Available in long acting dose

e.g. Oxybutinin(Ditropan), Tolterodine (Detrol),

Anticholinergics

potential side effects:dry mouthdrowsiness, fatiguealtered mentation with diminished

ability for complex problem solvinghypertension, tachycardiainsomnia

Treatment Medications: Estrogen

Local estrogen cream, suppositories or estring helpful with atrophic vaginal changes

help with symptomatic complaints of dryness, UI, UTI

Toileting strategies: less severely cognitively impaired & more mobile benefit more

Timed voidingPerson is toileted on a schedule &

voiding recorded on chartTheir 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

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

Vaginal pessaries

Worn intra-vaginally to support cystocele or uterine prolapse

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

Referral to medical specialist (urologist, urogynecologist, gynecologist):

Significant post void residual abnormal urine dipstick test pelvic organ prolapse constant dribbling frequent UTI’s No response to conservative

treatment

Questions/Comments?

Laura Robbs, Clinical Nurse Specialist-Continence

Trillium Health Centre

905-848-7580 ext. 3267

lrobbs@thc.on.ca

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