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Urinary incontinence is not in- by murplelake83


									By Tammy King, R.N.                      not just managing, urinary

       rinary incontinence is not in-
                                         incontinence. At Shepherd
       evitable, and it is reversible.
                                             Center in Atlanta,
It is a symptom of an underlying dis-
                                         incontinence is addressed
ease process or mechanical problem
of the lower urinary tract, not a dis-

ease in and of itself. In some cases the disorder is transient,

secondary to medications or a urinary tract infection. Other

times it’s chronic, lasting indefinitely unless properly diag-

nosed and treated.
                                                                      should emphasize
  At the urology department at Shepherd Center in Atlanta,               controlling
                                                                          or curing
urinary incontinence is considered a quality-of-life issue and        incontinence, not
                                                                      just managing it.
addressed aggressively. All cases warrant medical intervention.

                                                                          September 1995 23
      Taking Control
                                                                                             The core evaluation requires a thorough history, including med-
                              About                                                     ical, urologic, gynecologic and neurologic assessment,   with partic-
                       Urinary incontinence                                             ular attention to factors influencing bladder function. Duration,fre-
                        Urinary incontinecnce is the inappropriate                      quency, volume and type of incontinence should be described and
               l o s s of urine from failure to emit normal responses                   validated by having the client keep a voiding diary. Other     impor-
           a s the bladder fills. An Estimated 1.5 millIon non-institu-                 tant information includes associated illnesses, previous surgeries,
         tionalized adults have problems in controlling bowel move-                       current medications and bowel patterns.
        ments or urinations                                                                    A physical examination is required to rule out anatomical
                                                          percent of communlty- anomalies. The person’s mental status, mobility and dexterity,
                                                          percent may be classi- neurologic and abdominal status should also be evaluated.
                                                         ence rates are twice as Baseline measurements obtained may include urinalysis,
     high in woman as                                    er in older rather than serum creatinine or blood urea nitrogen, and post-void resid-
     younger adults. At                          nursing home residents suffer uals. Other tests, such as urine cultures, blood glucose and
      from U.    I                                                                          urinary cytology, may be useful.
            The incidence           incontinence increases progressively                                                          Specialized noninvasive
                                     46 to 6 4 h a v e an incidence of urinary                                                         and invasive tests
             incontinence of 7.5 per 1,00; those age 65-74 have                                                                              (see studying,
                 an incidence of 17.3 p e r 1,000; and people 75                                                                                  this page),
                       years and older have an incidence of                         Several specialized tests are available to assist in              should
           As a            46.7 per 1,000.                                  identifying the type and degree of incontinence:
      model center                        -T,K,                              l A cystometrogram (CMG) measures the ability of the bladder

      for the treatment of                                          to accommodate increasing infused volume at low pressures and
      spinal cord injury and having re-                           records the presence of uninhibited, involuntary bladder contractions. Used
      cently opened a 20-bed acquired brain injury              as the basic study in cases requiring more than a core evaluation, the CMG
      unit, Shepherd sees incontinence as a major plots intravesical pressure against volume. A spontaneous rise in bladder pres-
      clinical problem and a significant cause of sure of 15 cm of water or more that the client cannot inhibit establishes the pres-
      disability and dependency that can affect ence of detrusor instability.
      all age groups.                                        l The electromyogram of the sphincter (EMG) measures the activity of the

           Although determining the quantitative sphincter.
      impact of incontinence is difficult, clients         l Ultrasound of the bladder or kidneys may detect residual urine or                 hyddronephrosis.
      have graphically described the qualitative           l Cystourethroscopy, with or without cytology, is indicated in clients with hematuria

      impact. Feelings of embarrassment, or the recent onset of urgency or urge incontinence who are at high risk for carcinoma.
      shame, isolation, helplessness and loss of             l Uroflowmetry has a wide application in the evaluation of obstructive disease in

      self-esteem are common.                            men, but a limited role in the evaluation of women. The uroflowmetry measures the
           Difficulties encountered in living with time and force of the voided urine stream.
      incontinence also affect patients’ families;               l A videorodynamic evaluation is a series of tests that evaluates the function

      managing this condition creates a further fi- of the bladder and sphincter and uses fluoroscopy to view upper tract integrity
      nancial burden. The cost of managing urinary               and bladder neck mobility. Its role is limited to more elusive incontinence
      incontinence nationally is conservativelyestimat-             problems.
      ed at $10 billion annually (see cost, page 25).                     l Urethral pressure profilometry is cited by the National lnsti-

           A more effective approach is controlling inconti-             tutes of Health as a controversial test that proposes to mea-
      nence rather than managing it. The key to control is prop                 sure urethral pressure. Its predictive value has been
      er diagnosis. Shepherd Center’s urology department provides                   questioned, and it requires further validation be-
      a comprehensive array of diagnostic procedures and treatment in-                    fore it can be recommended for wide-
      terventions. Four urologists conduct clinics three days a week; di-                           spread use. -T.K.                       be performed se-
      agnostics tests are performed five days a week. Specialized nurses                                                        lectively. Treatment should
      perform tests and treatments, such as biofeedback, electrical stimu-             emphasize controlling or curing incontinence, not just managing it.
      lation, and client and family training and education. Referrals come                  Behavioral measures are another treatment approach through
      from clients as well as from physicians.                                         which control and cure of incontinence may be achieved. Pelvic
                                                                                       floor exercises, for example, help strengthen the voluntary peri-
      The Evaluation Process                                                           urethral and pelvic floor muscles. Benefits have been reported in
      The Agency for Health Care Policy and Research classifies incon-                  30 to 90 percent of women, but continued exercise is required for
      tinence into three categories: urge, stress and overflow. People suf-            long-term benefits. Habit training involves scheduled toileting on a
      fering from incontinence may have one type of incontinence or                    regular, planned basis, including frequent checks for dryness.
      mixed components. Evaluation must be tailored to the individual,                      Behavioral techniques increase awareness of the lower urinary
      taking into account clinical, cognitive, functional and residential tract and should be offered to motivated individuals who wish to
      factors to accurately identify the cause. People with stress urinary             avoid invasive procedures. People who have stress or urge inconti-
      incontinence, for example, which is anatomical or structural in na-              nence typically benefit from the behavioral approach, while those
      ture, require different treatment than those with urge incontinence,             with severe sphincter damage generally do not improve.
      which has a neurological or functional cause.                                         One technique used to teach clients to identify and strengthen

2 4 TeamRehab Report
the pelvic floor muscles is biofeedback. This                                                      manage bladder and urethral dysfunction in both
helps people visualize the exercise effort on a                                                    neurologically and non-neurologically impaired
screen and adjust their muscle activity to maxi-
mize results, When done properly, the increased
                                                         all nursing home people. This techniquemixed incontinence.people
                                                                                                   with urge, stress and
                                                                                                                                  is appropriate for
pelvic floor stiength immobilizes the urethra and        residents suffer ports suggest electrical stimulation may be up to
                                                             from urinary
provides the support needed for the urinary struc-                                                  87 percent effective? Few facilities offer electri-
tures, resulting in increased urinary continence.                                                  cal stimulation because the level of technical
                                                            incontinence.                           skill needed to provide the service is complex.
 Pharmacolog!c Approach                                                                                 Shepherd’s Urology Department is research-
Pharmacologic treatment is another alterna-                                                        ing the effects of electrical stimulation on pelvic
tive for managing UI, but has not been studied in well-de-                   floor strengthening in men post-radical prostatectomy who typically
 signed clinical trials. Drugs fall into three categories: bladder           suffer stress urinary incontinence. Participants use electricalstimu-
relaxants, direct smooth muscle relaxants and bladder outlet                                                    lation and perform pelvic floor exercis-
 stimulants.                                                                                                             es. Currently, 17 subjects have
     Bladder relaxants are generally used for urge incontinence and                               The                        finished the 12-week treat-
include anticholinergic medications. Direct smooth musclerelax-                              cost of                            ment and preliminary re-
 ants are antispasmodics that work directly on the bladder muscle to                    Incontinence                              suits show improve-
reduce bladder instability. They also have some anticholinergicef-                 Several studies have document-                    ment with inconti-
fects on the bladder. Calcium channel blockers are used for their de-       ed the costs of incontinence. One es-                      nence, voiding inter-
                                                                          tlmated the costs of nursing labor and vals and urgency.
   Classif ications                                                      su0Dlles for lncontlnent clients was $2,53                           Shepherd Cen-
   of Incontinence                                                      per’iay? Another study estimated the annu- ter was also a drug
   l&p                                                                 al costs of Incontinence In nursing homes as trial site for colla-
   0 Unstable bladder or detrusor hMabillty                            at least $9OO milllon to $I.,5 blllion. The gen urethral im-
   * D&rusor hyp0rr~exla,d~ru~r                                        same study indkited that the range of costs plantation, an op-
   sphincter dy~ey~~r~~                                                for managlng incontInence were $2,9O to tion that became
   * Mrusor hyperacth&y with impaIred contractlllty                     $!M.l minlmum and $3.77 to SI.l~O9 maxi- available to incon-
   * Urethral ~~~~~ll~t~                                                mum per day. The annual cost of lnconti- tinent people in
                                                                         nence for clients maneged with foley November 1994.
                                                                           catheters was about $2,S88, and ap- The Contigen TM
                                                                            proximately $2,072 to $4,532 per Bard Collagen Im-
                                                                               year for those managed wlth dls-                     plant treats inconti-
                                                                                   posable pads and reusable or                  nence caused by lack of
                                                                                     dk3posable diapers. ’                     control or poor control of
                                                                                                  -T.K,                     urine flow from the bladder.
   l Overflow from understih’e or a ~tttract!le detrusor                                                              The collagen is injected into tis-
   1 Overflow from outlet o~t~~lofl (female)                                                               sues around the urethra to add “bulk” and
                                                                             allow it to close tighter, preventing leakage.
pressant effect on the bladder. In people with heart disease, bladder             This is an outpatient procedure; the client usually leaves 30
effects must be weighed against the potential risk of urinary reten-         minutes post-treatment. Risk is minimal. Clinical studies have
tion. Imipramine, a tricyclic antidepressant, has anticholinergic and        shown that women have a greater than 80 percent chance of im-
direct relaxant effects on the detrusor and enhances the contractility       provement after treatment and an80 percent chance of remaining
on the bladder outlet. Both effects promote continence.                      improved after one year; for men, the figures are greater than 70
     Bladder outlet stimulants xe used in the treatment of stress in-        percent in both cases.                                                           m
continence and dyssynergia. Shepherd Center’s Urology Depart-
ment is involved in a research study evaluating the role of the long-             Tummy King, R.N., M.S.N., C.E.T.N., is the urology nurse man-
acting alpha antagonist, Terazosin, in the treatment of obstruction ager at Shepherd Center, where she has worked for 20 years. She
produced by vesicosphincter dyssynergia. With more than 30 sub               was named Shepherd’s Nurse of the Year in 1994.
jects pticipating, preliminary results are favorable; final data is               Shepherd Center, Urology Department, 220 Peachtree Road,
expected by July 1996.                                                       Atlanta, GA 30309; 4041352-2020.
     Terazosin appears to reduce symptomatology and decrease
residuals and vesicosphincter dyssynergia. However, bladder pres-            FOOTNOTES
                                                                             1, 2 Caputo, R.M.; Benson J.T. & McClellan E. (September, 1993).Intravagi-
sures don’t always decrease.
                                                                             nal maximal electrical stimulation in the treatment of urinary incontinence. The
     Estrogen is another pharmacological option for post-                    Journal of Reproductive Medicine, 38(9), 667-671.
menopausal women suffering from urge incontinence, urgency
and frecluency.                                                              3 Gray, M.; Dougherty, M, Urinaq Incontinence- Pathophysiology and Treat-
                                                                                 ment, Journal of Enterostom Therapy, 1987; 14 152-62.
Other Options                                                                    4 Feller, B, Americans Needing Help to Function at Home. USDHHS. PHS.
When conservative measures fail, other options are available. Elec-              Hyattsville, MD: Vital and Health Statistics of the.National Center for Health
trical stimulation involves stimul+at&g the pelvic musculature to                Statistics. September 14, 1983; 92:1-12.

                                                                                                                                               September 1995 25

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