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Ann M. Spenard RN, C, MSN
Courtney Lyder ND, GNP

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3 Describe common reversible causes of UI
3 Differentiate between chronic types of UI and
describe appropriate treatment options for each
diagnosis
3 Describe evaluation procedures, which are
appropriate for establishing diagnosis of UI in
the long-term care setting
3 Describe the process for completing the UI
Physical Assessment and History Form
3 Describe all the components for completing the
physical examination for urinary incontinence
d   

J. Complete Physical Assessment and


History form
2. Determine the type of urinary
incontinence
3. Complete Algorithm
O

  

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3 Ostimated J  to 35 of adults


3 > 5  of J.5 million nursing home
residents
3 A conservative estimated cost of $5.2
billion per year for urinary incontinence
in nursing homes

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3 Loss of self-esteem
3 Decreased ability to maintain
independent lifestyle
3 Increased dependence on caregivers for
activities of daily life
3 Avoidance of social activity and
interaction
3 Restricted sexual activity

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3 An increased propensity for falls
3 Most hip fractures in elders can be traced
to nocturia especially if combined with
urgency
3 Risk of hip fracture increases with
physical decline from reduced activity
cognitive impairments that may accompany a UTI
medications often used to treat incontinence
loss of sleep related to nocturia
’"


3 Aging
3 Medication side effects
3 High impact exercise
3 Menopause
3 Childbirth

  

     
3 Medications 3 Diet
Diuretics Caffeine
Antidepressants Alcohol
Antihypertensives
Hypnotics 3 Bowel Irregularities
Analgesics Constipation
Narcotics Fecal Impaction
Sedatives
6’
#
 
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3 Majority of urine production occurs at
rest
3 Bladder capacity is diminished
3 Quantity of residual urine is increased
3 Bladder contractions become
uninhibited (detrusor instability)
3 Desire to void is delayed
 
     

3 Stress
3 Urge
3 Mixed
3 Overflow
3 Total
 
     

3 d  Leakage of small amounts of


urine as a result of increased pressure
on the abdominal muscles (coughing,
laughing, sneezing, lifting)
3   Strong desire to void but the
inability to wait long enough to get to a
bathroom
 
 
      #

3
  A combination of two types,
stress and urge
3 m  Occurs when the bladder
overfills and small amounts of urine
spill out (bladder never empties
completely, so it is constantly filling)
3 ÷ Complete loss of bladder control
’%%%

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3 Failure
to store secondary to urethral
sphincter incompetence


 
   
3 Failure
to store, secondary to bladder
dysfunction
Involuntary bladder contractions
Decreased bladder compliance
Severe bladder hypersensitivity
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3 Combination of bladder overactivity


and stress incontinence
3 One type of symptom (e.g., urge or
stress incontinence) often predominates
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)
##
3 Urgency
3 Frequency
3 Nocturia, and/or urge incontinence
3 ANY COMBINATION - in the absence
of any local pathological or metabolic
disorder

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3 Loss of urine 3 Outlet obstruction


associated with Onlarged Prostate
over distention of Urethral Stricture
the bladder Fecal Impaction
3 Failure to empty 3 Neurological Conditions
Underactive bladder Diabetic Neuropathy
Vitamin BJ2 Low Spinal Cord Injury
deficiency Radical Pelvic Surgery
©  )
##

[    


3A medical term for overflow
incontinence, secondary to a neurologic
problem
3 However, this is ©m÷ a type of urinary
incontinence
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*Dµ Delirium
Dehydration*
*Rµ Restricted mobility
Retention
*Iµ Infection
Inflammation
Impaction
*Pµ Polyuria
Pharmaceuticals
X  #

3 Dehydration due to decreased fluid
intake; increased output from diuretics,
diabetes, or caffeinated beverages; or
increased fluid volume due to congestive
heart failure can concentrate the urine
(increased specific gravity) and also lead
to fecal impaction
3 The specific gravity of the urine can be
tested to determine whether or not the
resident is dehydrated
)
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3 PhysicalOxam
3 Female genitalia abnormalities
Rectocele
Urethral Prolapse
Cystocele
Atrophic Vaginitis
)
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3 Patient History
Focus on medical, neurological, genitourinary
Review voiding patterns and medications
Voiding diary
Administer mental status exam, if appropriate
3 Physical Oxam
General, abdominal and rectal exam
Pelvic exam in women, genital exam in men
Observe urine loss by having patient cough
vigorously
)
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    #
3 Urinalysis
Detect hematuria, pyuria, bacterimia,
glucosuria, proteinuria
Post void residual volume measurement by
catheterization or pelvic ultrasound

’
3 Lab
results from approximately the last
3 days:
Calcium level normal 8.6 - J .4 mg/dl
Glucose level normal fasting 65 - JJ mg/dl
BUN normal J - 29 mg/J ml Vm
Creatinine normal .5 - J.3 mg/dl
BJ2 level (within the last 3 years) normal 2 -
JJ pg/ml

*Normal lab values may vary depending on laboratory used.



*#  

3 Three day voiding diary should be
completed on the resident
3 Assessment should be completed 24
hours a day for 3 days
3 Make sure CNA·s are charting when the
resident is dry or not, the amount of
incontinence, if the voiding was
requested or prompted
)
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Focused Physical Oxam, including:
3 Pelvic exam to assess pelvic floor & vaginal
wall relaxation and anatomic abnormalities
including digital palpation of vaginal sphincter
3 Rectal exam to rule out fecal impaction &
masses including digital palpation of anal
sphincter.
3 Neurological exam focusing on cognition &
innervation of sacral roots 2-4 (Perineal Sensation)
3 Post Void Residual to rule out urinary retention
3 Mental Status exam when indicated
d 

3 Provocative
Stress Testing
3 Key components
Bladder must be full
Obtain in standing or lithotomy position
Sudden leakage at cough, laughing,
sneezing, lifting, or other maneuvers

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#
*


During a bed side exam the nurse should


observe for the following:
3 The presence of pelvic prolapse
(urethroceles, cystoceles, rectoceles)
It is more important that you identify the
presence of a prolapse than the particular
type
3 Is the vaginal wall reddened and/or thin?
3 Is the vaginal wall atrophied?
3 Is there abnormal discharge?

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#
*

   #
3 Testthe vaginal pH by taking small
piece of litmus paper and dabbing it in
the vaginal area
Document the vaginal pH
If the pH is >5 it is a positive finding

 
©
*

6

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3 Isthe foreskin abnormal? (Is the foreskin


difficult to draw back, reddened,
phimosis)
Phimosis is a general condition in which the
foreskin of the penis can not be retracted
3 Is there drainage from the penis?
3 Is the glans penis urethral meatus
obstructed?
'
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3 Nursing staff should perform a rectal


exam
Document if the resident has a large
amount of stool or the presence of hard
stool

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3 [hile completing a rectal exam for


constipation, note if you feel the
prostate enlarge
3 Please note findings
)
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3 [hen the nurse is inserting a finger into


the anus to check for fecal impaction,
the anal sphincter should contract
3 [hen the nurse is applying the litmus
paper to check the vaginal pH, the
vaginal muscle should contract
([hen both these muscles contract this
indicates intact reflexes)
*#’#


3A post void residual should be obtained


after voiding via a straight
catheterization or via the the bladder
scan
If the resident has > 2 cc residual the test
is positive
(Document the exact results on the
assessment form)
' ' 
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3 Complete a mini mental exam on the


resident
3 Chart the score on the assessment form
3 Score the resident on the number of
questions they answered correctly to the
total number of questions reviewed
)
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3 Rectocele
Anterior and downward bulging of the
posterior vaginal wall together with the
rectum behind it
’  
)
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3 Urethral Prolapse
Ontire circumference of urethral mucosa is
seen to protrude through meatus



)
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3 Cystocele
Anterior wall of the vagina with the
bladder bulges into the vagina and
sometimes out of the introitus
    
)
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3 Uterine Prolapse
The uterus falls into the vaginal cavity
 

x
# (
)
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3 Atrophic Vaginitis
Thinning of vaginal and urethral lining
causing dryness, urgency, decreased
sensation
6#
#
 

6

 

Guidelines recommend least


invasive evaluation and
treatment as baseline!!


 


Such as:
3 Atrophic vaginitis
3 Symptomatic urinary tract infections
(UTI)
x 
 

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3 Decreased glycogen
3 Decreased lactic acid
3 Increased vaginal pH
3 Increased risk of UTI·s

 
    

The vaginas of postmenopausal


women not being treated with
estrogen have been found to be
predominately colonized by O. coli
 
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3 Colonization of the vagina with
lactobacilli
3 Maintenance of acidic pH (<5)
 O O 
’
 
3A decrease in vaginal pH
3 Reemergence of lactobacilli
3 Colonization of the vagina rarely occurs
when the pH is below 4.5
Symptoms tend to re-appear
when estrogen treatment
ends!
m
 
 
   
3 Behavioral therapy
3 Pharmacotherapy
3 Olectrical Stimulation
3 Denervation/decentralization
3 Augmentation cystoplasty
3 Catheterization
3 Urinary diversion
)


 

3 Fluid management
3 Voiding frequency
3 Toileting assistance
Scheduled toileting
Prompted voiding
3 Bladder training
3 Pelvic floor muscle exercise
)
##
  + 
 
  
3 Bladder Training - techniques for
postponing voiding
3 Urge Inhibition Training - techniques
for resisting or inhibiting the sensation
of urgency
Bladder training & urge inhibition
training is strongly recommended for
urge & mixed incontinence & is
recommended for management of stress
incontinence
)

 

3 Pelvic muscle exercises


3 Offects of exercises
Support, lengthen and compress the
Urethra
Olevate the urethrovesical junction
Increase pelvic/muscle tone
)

 
3 Pelvic muscle (Kegel) exercises
3 Goal: to improve urethral resistance and
urinary control through the active
exercise of the pubococcygenus muscle
Components:
Proper identification of muscle (if able to stop
urine mid-stream)
Planned active exercise (hold for J seconds then
relax) 3 -8 times per day for a minimum of 8
weeks
)#
"

3 Veryhelpful in assisting patients in


identifying and strengthening pelvic
muscles
Give positive feedback for bladder training,
habit training and/or Kegels





3 Medications
To relax or augment bladder or urethral
activity


3 Pessary
3 Urethralinserts
3 Vaginal weights


d

 

 

3 More than J techniques


3 Repair hypermobility
3 Repair urethral support
3 Contigen Πimplants (ISD)
[ # ’

d 
,
3 Uncertain diagnosis/no clear treatment
plan
3 Unsuccessful therapy/resident requests
further therapy
3 Surgical intervention considered/
previous surgery failed
3 Hematuria without infection
’
d 

   #
3 Oxistence of other comorbid conditions:
Recurrent symptomatic urinary tract infection
Persistent symptoms of difficulty with bladder
emptying
Symptomatic pelvic prolapse
Prostate nodule enlargement, asymmetry, suspicion
of cancer
Abnormal post void residual urine
Neurological condition: multiple sclerosis, spinal
cord lesion/injury
History of previous radical pelvic or anti-
incontinence surgery
# 

3 Indwellingcatheters (urethral or
suprapubic) may be necessary for certain
residents with incontinence:
Urinary retention that cannot be corrected
medically or surgically, cannot be managed by
intermittent catherization and is causing
persistent overflow incontinence, symptomatic
UTIs
Pressure ulcers or skin lesions that are being
contaminated by incontinent urine
Terminally ill severely impaired residents
d


[ith correct diagnosis of UI,


expect more than 8 
improvement or cure rate
without surgery!!
O

  

Y   


   
      

d# -

3 Mrs. Martin:
She was admitted to a skilled nursing
facility following a hospitalization for
surgical repair of a fractured hip which
occurred when she fell on the way to the
bathroom.
6# &

3 Shewas living at home with her


daughter. Her medical history included
hypertension and osteoporosis. Mrs.
Martin·s daughter reported that her
mother frequently rushed to get to the
bathroom on time and often got out of
bed 4 to 5 times per night to urinate.
 6# 
© x&
3A physical therapy evaluation was done
to assess Mrs. Martin·s transfer status.
The therapist recommended assistive
ambulation and the nursing staff
implemented an every 2 hour toileting
schedule. This resident·s MDS
continence coding score after J4 days
was 3 (frequently incontinent).
 6# 
© x&   #
3 Mrs. Martin stated that she knew when she
needed to void but could not wait until the
staff could take her to the bathroom. She
could feel the urine coming out but could not
stop her bladder from emptying. Mrs. Martin
felt embarrassed about wearing a brief but felt
it was better than getting her clothing wet.
Her incontinence was sudden, in large
volumes and accompanied by a strong sense
of urgency.
 # 


3 Theproblems identified by the staff


during the first case conference included
urge incontinence and impaired
mobility.