SOAP – Urinary Incontinence – SỔ TAY LÂM SÀNG

Definition

A.Urinary incontinence in men and women is defined as an involuntary leakage of urine. Incontinence is further broken down into types of urinary leakage as follows.

1.Urgency is associated with a sense of an urgency to void. This may present suddenly. Precipitating factors include cold, the sound of running water, or washing hands, that is, putting hands in water.

2.Stress incontinence occurs with strain, exertion, sneezing, or coughing.

3.Mixed incontinence is the most common type of urinary incontinence for women. There is an urgency and exertion associated with it.

4.Post void incontinence is associated with post void residual urine in the urethra which leaks out after voiding.

5.Overactive bladder is associated with frequency, urgency, and nocturia. This may or may not have incontinence associated with it.

6.Incomplete urinary emptying (overflow) incontinence relates to incomplete emptying of the bladder due to an impaired detrusor contractility or a bladder outlet obstruction.

7.Functional/transient incontinence is usually self-limiting, transient, and potentially reversible due to treatable causes.

8.Inability to reach bathroom secondary to functional ability.

9.Reflex incontinence etiology is related to neurological dysfunction of the central nervous system.

Incidence

A.Globally, incidence affects 200 million people worldwide; in the United States, the number is 10 to 13 million.

1.The percentage of elderly patients who reside in long-term care facilities is between 50% and 84%.

B.Prevalence in men increases with age.

C.Prevalence in females.

1.60 to 79 years is 23.3%.

2.Over 80 years increases to 31.7%.

3.Of the types of incontinence, stress is most commonly seen in women who are younger than 65 years old. However, urge incontinence and mixed are more common among women older than 65 years. Stress incontinence affects both young and older women at a rate of 15% to 60%; of these, 25% are nulliparous young college athletes.

Pathogenesis

A.Urgency can be related to an uninhibited detrusor activity. This is most common in men.

B.Stress incontinence is generally due to pressure on the bladder, which can happen with coughing, sneezing, laughing, heavy lifting, and so forth.

1.Radical prostatectomy surgery is the most common cause in men due to damage to the prostatic apex. Transurethral resection of the bladder has less incidence of damage to the external sphincter and has a degree of less than 1%.

2.In women, stress incontinence is due to lax perineal muscles.

C.Overflow incontinence is the least common cause of incontinence due to impaired detrusor contractility and/or a bladder outlet obstruction. Impaired detrusor contractility is usually related to neurogenic etiologies. These include neuropathies such as mitral stenosis (MS), diabetes mellitus, meningomyelocele, lumbosacral nerve disease from tumors, prolapsed intravertebral discs, and higher spinal cord injuries.

D.Mixed incontinence is a combination incontinence of stress and urge; this is most common in women. The bladder outlet is weak and the detrusor is overactive. This may also include urethral hypermobility coupled with detrusor instability.

E.Transient incontinence refers to a temporary loss of urine due to causes that could be reversible such as delirium, infection, atrophic vaginitis or urethritis, pharmaceuticals, or a psychological etiology related to excess fluid intake. Impaired mobility, endocrine disorders, medications, fecal impaction, atrophic urethritis or vaginitis, infections, and delirium are also included in etiologies of transient incontinence.

F.Reflex incontinence for specific neurological disease processes include, but are not limited to, MS and demyelinating plaques of the frontal lobe or lateral columns. Cerebrovascular accident (CVA) or vascular compromise of particular areas of the brain may result in lower urinary tract dysfunction.

Predisposing Factors

A.Advanced age.

B.Aging process.

1.Atrophic vaginitis or urethritis.

2.Enlarged prostate (urge/stress).

C.Problems with gastrointestinal system.

1.Constipation.

2.Fecal impaction.

D.Cancer.

1.Pelvic organs.

2.Pelvic radiation within 6 months.

3.Prostate cancer (tumor status; urge/stress).

4.Prostate surgery or radiation.

E.Central nervous system (CNS) or spinal cord disorders.

1.Delirium or dementia.

2.Normal pressure hydrocephalus.

3.Neuropathies.

F.Connective tissue disorders.

G.Depression medications.

H.Obesity.

I.Pelvic organ prolapse (uterus/bladder).

J.Chronic obstructive pulmonary disease (COPD).

K.Mobility.

L.Sleep apnea.

M.Urinary tract stones or urinary tract infection (UTI), more than two episodes a year.

Subjective Data

A.Common complaints/symptoms.

1.Sudden onset of the need to urinate.

2.Urine leakage after emptying bladder.

3.Unable to make it to the bathroom with the urge to urinate.

4.Feeling of incomplete emptying of the bladder with urination.

5.Burning with urination.

6.Flu-like symptoms.

7.Morbidity related to incontinence.

a.Cellulitis.

b.Constant skin irritation and sores.

c.Falls and subsequent fractures.

d.Perineal candida infections.

e.Pressure sores.

f.Sleep deprivation.

8.Psychological morbidity related to incontinence.

a.Depression.

b.Poor self-esteem.

c.Sexual dysfunction.

d.Social withdrawal.

9.Urine leakage.

10.May complain of hygiene issues.

B.Common/typical scenario.

1.Patients do not typically like to discuss incontinence, but will report varying degrees of urine urgency, frequency, or pain when urinating that may be minor, situational, or even debilitating.

C.Family and social history.

1.Family and social history is noncontributory.

D.Review of systems.

1.Dermatological: Ask about skin infections, itchiness, redness, and pressure sores.

2.Psychological: Ask about social involvement, sexual functioning, mood, and sleep habits.

3.Genitourinary: Ask about moisture felt in underwear, leakage issues, itching, burning during urination, frequency, urinating at night, perineal irritation.

4.Gastrointestinal: What is the typical bowel pattern? Any there complaints of constipation or impaction?

Physical Examination

A.General.

1.Appearance.

2.Signs of depression.

3.Any distress.

4.Anxiety.

B.Gastrointestinal: Abdominal distention.

C.Musculoskeletal.

1.Joint stiffness.

2.Mobility.

3.Range of motion (ROM).

4.Use of assistive devices.

D.Neurological with emphasis on cognition, functional status, and pyramidal and extra-pyramidal symptoms. Integrity of sacral roots S2, S3, and S4; resting and follitional anal tone; and anal wink reflex. Evaluate for peripheral neuropathy.

E.Male.

1.Visual examination of the penis, enlarged prostate, and scrotum.

2.Review past medical history (PMH) for prostate issues.

F.Female.

1.Review PMH for prolapse of pelvic organs and perineal irritation.

Diagnostic Tests

A.Laboratory.

1.Chemistries with renal function and complete blood count (CBC).

2.Prostate specific antigen (PSA) level.

3.Urine analysis with cytology and microscopy.

B.Radiology.

1.Post residual bladder scan.

2.Renal ultrasound (US) if indicated by abnormal renal laboratory studies.

3.CT of brain if hydrocephalus is suspected.

Differential Diagnosis

A.CNS or spinal cord disorders.

B.Connective tissue disorders.

C.Constipation or fecal impaction.

D.Medication induced.

E.Normal pressure hydrocephalus.

F.Neuropathy, diabetic neuropathy.

G.Obesity.

H.Pelvic organ prolapse (uterus/bladder).

I.Sleep apnea.

J.Urinary tract stones.

K.UTI.

Evaluation and Management Plan

A.General plan.

1.Perform a full medication review and reconciliation.

2.Perform multidisciplinary rounds for geriatric patients and include continence strategies for those who are incontinent, all patients over 75 years of age, and those who are frail. Include pharmacist, dietician, radiation therapy (RT), prothrombin time (PT)/OT, advanced practice provider, case management, social worker, and caregivers when indicated.

4.Patient safety.

a.Modify inpatient environment; include toileting into hourly rounds, place call light within reach, use lights at night, and clear the walkway to bathroom/bedside commode.

b.Patient/family caregiver education on use of the call light for assistance.

c.Evaluate for safe discharge on admission utilizing case management and social worker to collaborate with family and caregivers. Include nurses, APNs, PT/OT, dietician, pharmacist, and physicians.

d.Request toileting rounds for patient safety to include an order for bed and chair alarms for those elderly patients with urgency and frequency.

e.Urinals at bedside for male patients, bedpans for those unable to ambulate or get up to use a commode.

5.Correct underlying medical etiology or physical deficit if possible, which may include medication revisions, correction of vision/hearing with assistive devices, and use of ambulatory devices.

B.Patient/family teaching points.

1.Pelvic floor exercises.

2.How to use absorbent products.

3.Approaches to dealing with incontinence.

4.Modifications to diet and lifestyle may help patient control incontinence to a certain degree.

C.Pharmacotherapy.

1.Medications depend upon the type of urinary incontinence being treated.

2.Medications may not be effective in stress incontinence.

3.Anticholinergics (antimuscarinics) block cholinergic receptors of the bladder and decrease contractility.

4.All antimuscarinics are contraindicated in narrow angle glaucoma, gastric retention, and if post void residual (PVR) is greater than 150 L. Educate for side effects. Costs vary.

5.Benign prostatic hypertrophy (BPH)-related incontinence: Alpha blockers have extensive precautions for administration. Orthostatic hypotension, hypotension, bradycardia, vertigo, priapism, cautious administration, and lab surveillance in patients with hepatic impairment should be considered.

6.UTI: Antibiotic-focused therapy, either oral or intravenous (IV), depending upon the severity and hemodynamic status of the patient.

7.Other treatments.

a.Barrier creams.

b.Oral multivitamins with zinc.

c.Absorbent undergarments.

d.Pelvic floor exercises.

e.Transient incontinence; treat the underlying cause, that is, infection, outlet obstruction, and so forth.

f.Surgical interventions.

D.Discharge instructions.

1.Evaluate for safe transfer of care from initiated unit, that is, ICU to floor, floor to home, or other institution.

2.Doctor to doctor report or APN to doctor/APN report.

3.Accurate discharge summary of events including chief complaint and events leading up to admission and medical nursing care during hospitalization.

4.Copy of discharge summary to the family or caregivers, primary care provider, and specialists to ensure communication and history of recent events are transferred to community providers. Inpatient providers should state patient’s condition upon discharge and the patient’s ability to transfer to the next level of care.

5.Thorough medication reconciliation; ensure obsolete medications are removed from medical admissions record (MAR) and home medication list.

6.Separate education for medication reconciliation regarding discontinued medications, new medications, and administration.

7.Education for signs and symptoms of worsening condition, what is expected to happen, and readmission concerns.

8.Discharge education regarding physician follow-up; medications and instructions on medications; any medical treatments that require an explanation, including physical therapy or wound care therapy; and breathing treatment or injections, to name but a few.

9.Use of any new assistive devices, walkers, canes, braces, or hearing devices.

10.Education on making the incontinent patient’s home safe from falls, such as removing scatter rugs and keeping lights on.

Follow-Up

A.Patient should follow-up with the provider in 2 weeks to assess progress in treatment plan.

Consultation/Referral

A.Urology.

B.Primary care provider/gerontologist.

C.Wound care if indicated.

D.Physiotherapist: Pelvic floor exercises, bladder training, and strategies to maintain continence.

Special/Geriatric Considerations

A.Case management and social worker are utilized to ensure safe discharge to appropriate level of care.

B.Arrange for delivery of any durable medical equipment to the patient’s assisted living, adult living, group home, or home. Considerations of insurance coverage and deductible amounts are important for elders on fixed budgets. Financial resources and availability of social support through appropriate government resources is important for safe transition, especially to independent living and home.

1.Medications: Ensure insurance is available for medications and durable medical equipment necessary for safe patient discharge, such as bedside commode, and so forth.

2.If possible, arrange first follow-up medical appointments with appropriate physicians, and/or specialists (urologist).

3.If home therapy is needed for wound therapy, ensure appointments for home visits are set up.

C.If indicated, set up home health visit to provide appropriate support in arranging first appointments.

D.Discuss with patient, caregiver, and/or family.

1.Signs and symptoms to monitor.

2.Common occurrences.

3.Readmission concerns.

Bibliography

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5) (5th ed.). Arlington, VA: American Psychiatric Association.

Fauci, A. S. (2008). Nervous system dysfunction. In A. S. Fauci, E. Braunwald, D. L. Kasper, S. L. Hauser, D. L. Longo, J. L. Jameson, & J. Loscalzo (Eds.), Harrison’s principles of internal medicine (17th ed., pp. 139–180). New York, NY: McGraw-Hill Professional.

Fletcher, K. (2012). Dementia. In M.,Boltz, E.,Capezuti, T. Fulmer, & D. Zwicker (Eds.), Evidence-based geriatric nursing protocols for best practice 4th ed. pp. 163–185. New York, NY: Springer Publishing Company.

Fulmer, T., & Zwicker, D. (2012). Evidence-based geriatric nursing protocols for best practice (4th ed., pp. 186–199). New York, NY: Springer Publishing.