Urinary Incontinence

I would be remiss if I did not discuss urinary incontinence as a major issue in long-term care (LTC)  facilities.   Urinary incontinence (UI) is the inability to control urination. It affects people of all ages but women are twice as likely as men to develop incontinence. According to the literature, at least one in ten people over age sixty-five have a problem with UI. Many people deny the presence of this problem due to the associated social stigma. It is embarrassing and uncomfortable but it can usually be improved. However, Urinary Incontinence is referred to as overactive bladder (OAB) Continuous incontinence occurs when a fistula develops between the bladder and vagina and may require surgical intervention.

There are four types of UI.

Urge Incontinence occurs when there is a sudden urge to void with the inability to control urination. This condition is also referred to as overactive bladder and occurs with the involuntary contraction of the bladder muscle (detrusor instability). Urge  incontinence can also be caused by neurological conditions such as multiple sclerosis and Parkinson's disease. UI is not a disease but a symptom and can be caused by everyday habits, physical problems, and medical conditions.  Low hormone levels after menopause and urinary tract infections are also contributing factors. It most often affects older women.

Stress Incontinence occurs when the sphincter opens under sudden pressure such as coughing, sneezing, heavy lifting or laughing. It is more common in women who’ve had prolonged or difficult labors, are obese or have pelvic floor weakness or prolapse. A combination of urge and stress factors are referred to as mixed incontinence.

Overflow incontinence when the bladder is constantly full and leakage occurs.

Functional incontinence occurs with physical disabilities, external obstacles and problems with thinking or communicating that will prevent a person from getting to the bathroom before voiding occurs.

Transient or temporary incontinence can occur as a result of a urinary tract infection or side effects from some medications. Treatment of the condition or change of the causative drug enables the incontinence to subside.

There are numerous causes for UI. These include alcohol, caffeine, (in drinks like tea and coffee) overhydration, bladder irritation caused by carbonated beverages, highly spiced foods, acidic foods such as tomatoes and citrus fruit. Cardiac and antihypertensive medications, diuretics, muscle relaxants and sedatives all can contribute to bladder control problems

Constipation may also be a cause, as the rectum and bladder share many of the same nerve supply. When there is a hard compacted stool in the rectum, the nerves can become overactive which can result in UI. Aging of the bladder muscle leads to decrease in bladder capacity to store urine and can increase OAB symptoms

Toileting in advance of need (TIAN) was one of the older methods to avoid or decrease incontinent episodes.  Residents were put on a bladder observation program for seventy-two hours after admission.Times and amounts of urination were observed and documented. Based on that information residents were toileted in advance of need, usually before and after meals and at two to three-hour intervals. This decreased incontinent episodes preserved residents’ dignity, protected the skin from prolonged moisture and was certainly labor saving.

It may be beneficial for the resident to have a urological consultation as other medications and treatments may be prescribed. Many medications may be prescribed to control OAB.

Anticholinergics can block the action of acetylcholine that triggers abnormal bladder contractions associated with OAB.These bladder contractions can make the resident feel the need to urinate even though the bladder is not full.

Ditropan xl, Oxidative and Vesicare are the medications I have seen more frequently prescribed.The extended release medication is taken once daily and had fewer side effects than other anticholinergics which are taken multiple times daily. Vesicare has been effective in treating urgency, frequency, and leakage. Most common side effects are dry mouth and constipation.

Mirabegron is a drug which relaxes the bladder muscle allowing increase in bladder capacity and may also increase the amount of urination at one time, which helps to empty the bladder more completely.

Tricyclic Antidepressants also help in controlling OAB. These medications allow the bladder muscles to relax while causing the smooth muscle at the bladder neck to contract. The drug Imipramine is often prescribed for mixed incontinence. It should be taken at HS (hour of sleep) as it causes drowsiness.

Antidiuretic  Hormone(ADH) is a drug which reduces the amount of urine produced. This can help with incontinence that occurs from a full bladder.

Low-dose topical estrogen in the form of vaginal cream may help rejuvenate deteriorating tissues in the vagina and urinary tract and may improve some incontinent symptoms.

The physician may also prescribe Physical Therapy treatments to improve OAB. These treatments may include electrical stimulation to the pelvic floor. Biofeedback, kegel and relaxation exercises and exercises to improve abdominal and core muscle control may be beneficial.

Bladder training (learning to hold on for longer) should be taught and encouraged.

Men may also suffer from UI. Over fifty per cent of men after prostate surgery experience some degree of UI. This can range from “dribbles” after voiding to full loss of bladder control. Kegel exercises may be beneficial but should be done at least ninety times daily. These exercises can be done anywhere anytime and takes only a few minutes. It is important to remind the resident to do them

The results of all prescribed medications and treatments should be observed and documented.