urinary incontinence case study ppt

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• v.10(2); 2021 Feb

Improving Assessment, Diagnosis, and Management of Urinary Incontinence and Lower Urinary Tract Symptoms on Acute and Rehabilitation Wards That Admit Adult Patients: Protocol for a Before-and-After Implementation Study

Dianne lesley marsden.

1 Hunter Stroke Service, Hunter New England Local Health District, Newcastle, Australia

2 Faculty of Health and Medicine, University of Newcastle, Newcastle, Australia

3 Brain and Mental Health Program, Hunter Medical Research Institute, Newcastle, Australia

4 Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery, Newcastle and Melbourne, Australia

Kerry Boyle

5 Belmont Hospital, Hunter New England Local Health District, Newcastle, Australia

Louise-Anne Jordan

Judith anne dunne.

6 Rankin Park Centre, Hunter New England Local Health District, Newcastle, Australia

7 John Hunter Hospital, Hunter New England Local Health District, Newcastle, Australia

Fiona Minett

8 Manning Hospital and Wingham Hospital, Hunter New England Local Health District, Taree, Australia

Amanda Styles

9 Armidale Hospital, Hunter New England Local Health District, Armidale, Australia

10 Tamworth Hospital, Hunter New England Local Health District, Tamworth, Australia

Jaclyn Birnie

Sally ormond.

11 Calvary Mater Newcastle, Newcatle, Australia

12 Port Macquarie Hospital, Mid North Coast Local Health District, Port Macquarie, Australia

Amanda Buzio

13 Coffs Harbour Hospital, Mid North Coast Local Health District, Coffs Harbour, Australia

Sandra Lever

14 Ryde Hospital, Northern Sydney Local Health District, Sydney, Australia

15 Susan Wakil School of Nursing and Midwifery, The University of Sydney, Sydney, Australia

Michelle Paul

16 Continence Service, Hunter New England Local Health District, Newcastle, Australia

Kelvin Hill

17 Stroke Foundation, Melbourne, Australia

18 Stroke Theme, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia

Michael R P Pollack

John wiggers.

19 Health Research and Translation, Hunter New England Local Health District, Newcastle, Australia

20 Public Health Program, Hunter Medical Research Institute, Newcastle, Australia

Christopher Oldmeadow

21 Clinical Research Design & Statistics, Hunter Medical Research Institute, Newcastle, Australia

Dominique Ann-Michele Cadilhac

22 Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Australia

23 Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Australia

The I-SCAMP Project Team

24 see Acknowledgments

Urinary incontinence (UI) and lower urinary tract symptoms (LUTS) are commonly experienced by adult patients in hospitals (inpatients). Although peak bodies recommend that health services have systems for optimal UI and LUTS care, they are often not delivered. For example, results from the 2017 Australian National Stroke Audit Acute Services indicated that of the one-third of acute stroke inpatients with UI, only 18% received a management plan. In the 2018 Australian National Stroke Audit Rehabilitation Services, half of the 41% of patients with UI received a management plan. There is little reporting of effective inpatient interventions to systematically deliver optimal UI/LUTS care.

This study aims to determine whether our UI/LUTS practice-change package is feasible and effective for delivering optimal UI/LUTS care in an inpatient setting. The package includes our intervention that has been synthesized from the best-available evidence on UI/LUTS care and a theoretically informed implementation strategy targeting identified barriers and enablers. The package is targeted at clinicians working in the participating wards.

This is a pragmatic, real-world, before- and after-implementation study conducted at 12 hospitals (15 wards: 7/15, 47% metropolitan, 8/15, 53% regional) in Australia. Data will be collected at 3 time points: before implementation (T 0 ), immediately after the 6-month implementation period (T 1 ), and again after a 6-month maintenance period (T 2 ). We will undertake medical record audits to determine any change in the proportion of inpatients receiving optimal UI/LUTS care, including assessment, diagnosis, and management plans. Potential economic implications (cost and consequences) for hospitals implementing our intervention will be determined.

This study was approved by the Hunter New England Human Research Ethics Committee (HNEHREC Reference No. 18/10/17/4.02). Preimplementation data collection (T 0 ) was completed in March 2020. As of November 2020, 87% (13/15) wards have completed implementation and are undertaking postimplementation data collection (T 1 ).

Conclusions

Our practice-change package is designed to reduce the current inpatient UI/LUTS evidence-based practice gap, such as those identified through national stroke audits. This study has been designed to provide clinicians, managers, and policy makers with the evidence needed to assess the potential benefit of further wide-scale implementation of our practice-change package.

International Registered Report Identifier (IRRID)

DERR1-10.2196/22902

Introduction

Urinary incontinence (UI) and lower urinary tract symptoms (LUTS) are commonly experienced by adults admitted to hospitals, also referred to as inpatients, and contribute to the complexity and cost of providing care to these individuals. UI types include functional, neurogenic, stress, overflow, continuous, urgency, and mixed UI [ 1 , 2 ]. LUTS include acute and chronic urinary retention, frequency, urgency, and nocturia [ 1 , 2 ]. Surprisingly, data on the prevalence of UI and LUTS in adult inpatients are limited. However, these conditions have been reported to range from 10% to 45% of patients receiving acute and subacute care in hospitals [ 3 - 5 ]. The often-taboo subject of UI is significantly associated with poorer patient outcomes, including urinary tract or urinary catheter–associated infections [ 6 , 7 ], incontinence-associated pressure injury [ 8 ], falls [ 9 ], and pain associated with these conditions [ 6 , 7 ]. People with UI are twice as likely to experience depression and are more often socially isolated [ 6 , 7 , 10 ]. UI is associated with increased carer stress and is a main reason for carers feeling unable to continue in the carer role, leading to residential care admissions [ 11 ]. Although UI and LUTS are often complex and not always curable, with appropriate clinical care, symptoms can be managed and complications can be avoided.

International and Australian clinical practice guidelines provide recommendations for optimal care for UI and LUTS, based on the current, albeit limited research evidence [ 1 , 12 - 16 ]. Stroke is an example where UI and LUTS care has been included in condition-specific guideline recommendations [ 17 - 19 ]. Australian stroke guideline recommendations for optimal care are that all people poststroke are screened for continence issues and that those with symptoms receive an assessment, diagnosis, and a tailored inpatient and postdischarge management plan [ 17 ]. In the 2017 National Stroke Audit Acute Services, of the one-third of inpatients with UI, only 18% received a management plan [ 20 ]. In the 2018 National Stroke Audit Rehabilitation Services, of the 41% of inpatients who had UI, 52% had a documented management plan [ 21 ]. These results indicate an evidence-practice gap in current inpatient UI/LUTS care.

Although peak bodies recommend that health services have systems for optimal UI and LUTS care [ 1 , 15 , 17 ], there is little reporting of effective inpatient interventions to systematically deliver this care, as demonstrated in stroke care. In a recent Cochrane review, it was identified that there was limited evidence for the effectiveness of UI interventions poststroke [ 6 ]. The review included 20 trials (with 1338 participants, reporting 21 comparisons), with the authors reporting that the risk of bias was impossible to judge for many of the included studies because of poor reporting. The authors call for more robust multicenter trials.

As part of our formative quality improvement research [ 22 ], in 2009-2010, we translated high-level UI and LUTS guideline recommendations into an intervention that presents clear, concise, and explicit optimal inpatient care in a user-friendly format [ 23 ]. We collaborated with health service clinicians and managers from 3 rehabilitation services in the Hunter Region, Australia, to synthesize the best-available evidence into our Structured urinary Continence Assessment and Management Plan (SCAMP) intervention that was specifically designed for inpatients poststroke in metropolitan rehabilitation units [ 22 ]. Our SCAMP intervention consists of (1) a 4-page clinical decision support tool guiding comprehensive UI and LUTS assessment, diagnosis, and management; (2) the associated clinical practice guideline; and (3) supporting web-based education modules [ 22 ]. Stroke clinicians using the SCAMP intervention identified that it has the potential to be applicable across a range of hospitals in different health districts, for inpatients with a range of diagnoses including stroke, and across the phases of inpatient care.

The aim of this study is to determine if the implementation of our SCAMP intervention is feasible and effective across this range of clinical scenarios.

Research Questions

Does the implementation of our SCAMP intervention increase the proportion of inpatients with UI/ LUTS who have an individually tailored UI/ LUTS management plan?

• Inpatients with UI/LUTS who have an assessment and diagnosis of types of UI/LUTS?
• Inpatients with UI/LUTS and their caregivers who are involved in the development of the management plan?
• Clinicians who rate their knowledge, skills, and confidence in identifying the types of UI/LUTS and assessing, diagnosing, and managing UI/LUTS as good or very good?
• Does the implementation of our SCAMP intervention reduce in-hospital complication rates associated with UI/LUTS or urinary catheterization?
• Are any improvements in the above outcomes maintained at 12 months after implementation begins?
• What are the potential economic implications (cost and consequences) for hospitals implementing our SCAMP intervention?

This will be a pragmatic, real-world, before- and after-implementation study conducted at 12 hospitals. Data will be collected at 3 time points: before implementation (T 0 ), immediately after the 6-month implementation period (T 1 ), and again after a 6-month maintenance period (T 2 ; Figure 1 ). Data will be collected from medical record audits and clinician questionnaires. An economic evaluation from the perspective of hospitals will be conducted. We will report our primary findings according to the Standards for Reporting Implementation Studies (StaRI) [ 24 , 25 ].

Study design and data collection timeframes.

Target Sites

Eleven hospitals in New South Wales (NSW) and 1 in Queensland, Australia, participated in our study. The hospitals are located in 4 health service districts. The hospitals were a convenience sample. Ten of the hospitals are located in 2 Local Health Districts that form part of the NSW Regional Health Partners, a Centre for Innovation in Regional Health (accredited by the National Health and Medical Research Council). Lead clinicians from the other 2 hospitals heard about our SCAMP intervention at conference presentations and approached the lead author about adopting the intervention.

Fifteen wards where patients after stroke are admitted are participating ( Table 1 ). In Australia, people after stroke are cared for on wards that admit people with a range of conditions. This care may be provided in a stroke unit embedded in the ward or as part of the general ward population. This study was instigated by stroke clinicians who identified UI/LUTS inpatient care needed to be improved on their ward for people after stroke and potentially for other inpatient populations. To be eligible to participate, key ward clinicians and managers had to identify that UI/LUTS care was an issue for their ward and that they were willing to commit resources toward improving optimal UI and LUTS care by implementing the SCAMP intervention. The characteristics of each ward are outlined in Table 1 . A total of 47% (7/15) of the wards are in 4 hospitals in 2 major cities, and the other 53% (8/15) wards are in 8 hospitals in inner regional locations [ 26 ]. The wards included 43% (7/15) rehabilitation wards, 27% (4/15) acute medical wards with an embedded stroke unit, 13% (2/15) wards with both acute and rehabilitation inpatients, 7% (1/15) rehabilitation ward with an embedded stroke unit, and 7% (1/15) medical ward. Before commencing the study, the investigators from each ward nominated the target adult inpatient populations from their ward to be included in the study of acute stroke, acute medicine, and/or rehabilitation for any condition, including stroke ( Table 1 ). Clinician representatives from each site have been project team members from the outset (including authors KB, JAD, JS, FM, AS, JB, SO, AB, and SL).

Characteristics of the participating wards.

a SCAMP: Structured urinary Continence Assessment and Management Plan.

Target Population

The population targeted by our practice-change package is clinicians (full time, part time, and casual) employed in each participating ward (including nurses, Nurse Unit managers, physiotherapists, occupational therapists, speech pathologists, social workers, and doctors). Participating clinicians are general medical, rehabilitation, or neuroscience clinicians who are not identified as continence or urology specialists. There are no exclusion criteria, as the study is a service improvement initiative, clinicians will not be consented to receive our practice-change package. The unit of analysis is hospital performance, based on patient-level data.

Practice-Change Package (Study Intervention)

Our practice-change package is designed to support clinicians and health services to deliver guideline-recommended UI and LUTS care. It consists of our SCAMP intervention that we will implement using evidence-based implementation strategies.

Intervention

In 2018, we reviewed all 3 components of our SCAMP intervention with experts from stroke, continence, rehabilitation, and urology to ensure that they met the current best-evidence UI and LUTS care for the majority of adult inpatient populations. Our SCAMP intervention consists of the following:

• The 4-page SCAMP decision support tool, which has been approved by the Hunter New England Local Health District Forms Committee
• The associated Clinical Practice Guideline that includes UI Management Flowcharts modified from the International Continence Society flowcharts
• Eight web-based education modules and a local module on how to use the SCAMP decision support tool (a PowerPoint presentation with a voice-over). The web-based modules cover information on normal bladder function, why continence is an issue after stroke, and 6 of the common inpatient UI and LUTS types and are hosted on the Stroke Foundation website [ 27 ]

Implementation Strategies

To enhance the success of our SCAMP intervention, we will use evidence-based theoretical approaches for implementation [ 28 , 29 ]. As there is no one all-encompassing theory that guides implementation of a complex multicomponent intervention, we have chosen to use complementary approaches that align best with the various components of the study, including the project design, assessment of the barriers and enablers, systematic planning and development of implementation and sustainability processes, and the evaluation of the project [ 29 ]. The Knowledge to Action framework is a process framework that guides implementation [ 23 ]. The Theoretical Domains Framework is the determinant framework that will help us identify the constructs that may influence implementation (barriers and facilitators) [ 30 , 31 ]. The evaluation plan is informed by the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework [ 32 , 33 ].

Implementation strategies were selected to overcome barriers identified by project team members with experience in implementation science and known barriers to clinicians implementing guideline recommendations identified in the literature [ 34 , 35 ]. Textbox 1 outlines the planned implementation strategies to support the practice change and how these strategies align with the Expert Recommendations for Implementing Change [ 36 ].

Summary of planned implementation strategies.

• Build a coalition. A coalition has been built that includes 15 wards across 12 hospitals, peak government and nongovernment bodies, and multiple universities.
• Work with educational institutions. Coalition members include institutions that provide tertiary and/or professional development education to the target groups.
• Develop academic partnerships and use data experts. Coalition members include academics from multiple institutions with expertise in implementation science, statistics, health economics, and data management.
• Centralize technical assistance. Sites will be supported by a centralized research team who will provide the evidence-based intervention (Structured urinary Continence Assessment and Management Plan; SCAMP); develop implementation resources in consultation with the team (including education materials and Implementation Training Workshops for site leaders); and evaluation resources (data collection tools, data storage, data analysis, and reporting).
• Access new funding. Sites will be supported to conduct the audits with small grants secured by the research team.
• Identify and prepare champions. Each site will have a local project lead and site champions who will drive the project locally. Leads will be senior clinicians, managers, or educators who have influence over local practice.
• Recruit, designate, and train for leadership. Site leaders will attend 2 training workshops that will include an overview what implementation research is and strategies for implementing evidence-based practice, overcoming barriers, generating sponsorship, communication, and using mixed methods for evaluation.
• Create a learning collaborative. A learning collaborative will be developed where sites learn from and share with each other to improve implementation.
• Develop resource-sharing agreements. Sites will share any implementation resources they develop with other members of the collaborative. This will be facilitated by a shared cloud–based repository.
• Organize clinician implementation team meetings and provide ongoing consultations. Project team members from each site will meet at 2 implementation workshops plus monthly teleconferences for education, consultation, and collaboration.
• Identify barriers and facilitators. Local sites will use the Behaviour Identification and Mitigation tool [ 37 ] to develop a local implementation plan.
• Tailor strategies and promote adaptability to meet local needs. Local implementation plans will tailor the implementation strategy and adapt the intervention to suit local needs.
• Distribute educational materials. Local sites will facilitate staff undertaking the education modules that inform the SCAMP decision support tool.
• Conduct educational meetings. Sites will conduct local education meetings to educate staff.
• Change record systems. The SCAMP decision support tool will be implemented at all sites. Paper or electronic versions will be used based on local needs.
• Audit and provide feedback. Before-implementation audit data will be fed back to each site.
• Remind clinicians. A poster display of different continence types and possible management solutions will be made available to all sites.

To identify ward-specific barriers, local teams will use the Barrier Identification and Mitigation tool [ 37 ]. Local teams will observe and ask clinicians about the SCAMP decision support tool and guideline and walk through the process to simulate real ward circumstances. From the data they collect during the identification phase, each team will summarize and prioritize barriers and then develop a local action plan. The practice-change package will be adapted by each site to suit their local context.

Our primary outcome is the change (T 1 -T 0 ) in the proportion of inpatients who have an individually tailored UI/LUTS management plan. This will be determined via a medical record audit.

Our secondary research outcomes are:

• Inpatients with UI/LUTS who have an assessment and diagnosis of types of UI/LUTS, determined via a medical record audit
• Inpatients with UI/LUTS and their carers who are involved in the development of the management plan, determined via a medical record audit
• Clinicians who rate their knowledge, skills, and confidence in identifying the types of UI/LUTS and in assessing, diagnosing, and managing UI/LUTS as good or very good, determined via a clinician questionnaire
• The change in in-hospital complication rates associated with UI/LUTS or urinary catheterization, determined via medical record audit (T 1 -T 0 )
• The change in the aforementioned outcome measures at 12 months after implementation begins (T 2 -T 0 , T 2 -T 1 )
• The potential economic implications for hospitals implementing our SCAMP intervention, determined using a cost-consequences analysis method

Data Collection Procedures

Data will be collected at 3 time points ( Figure 1 ): before implementation (T 0 ), after a 6-month implementation period (T 1 ), and after a 6-month maintenance period (T 2 ). Before-implementation data will be used to tailor the intervention to each ward.

Medical Record Audit

Records of adults aged ≥18 years with the ward-nominated conditions who are discharged from each participating ward will be included. To reduce selection bias, we will include consecutive records of patients discharged from each ward for each month of the 3-month data collection period.

Records will be screened to determine if the patient had UI/LUTS, including an indwelling urinary catheter, during their stay on the participating ward. During screening, we will extract data, including demographic, characteristic information, continence status, and how the UI/LUTS status was determined. Patients will be excluded from the full medical record audit if they are determined to have had no UI/LUTS during admission to the participating ward—deemed palliative/at the end of life and died during their admission or were discharged with this care type. People deemed to be at the end of life will be excluded as their management goals for UI/LUTS are usually different from those receiving acute and rehabilitative treatment. Patients who have an unexpected death, for example, cardiac arrest, during admission will be included.

Medical record audits of patients with UI/LUTS, including those with an indwelling urinary catheter, will be performed for 15 records for each month or until all patients discharged during that month have been screened, whichever occurs first. The medical record audit tool is based on questions in the Australian Stroke Foundation National Audits [ 20 , 38 , 39 ] and the content of the SCAMP decision support tool. The medical record audit tool was designed by KB and DM, piloted and refined by the project team members, including KB, J Dunne, JS, FM, AS, JB, SO, AB, KP, and SL, who will be performing the audits. The authors then examined the tool for face validity. Medical record audits will be conducted at each hospital by the project team members from that hospital and other local clinicians with legitimate access to the medical records, as per local health service requirements for patient privacy and confidentiality. A web-based medical record audit data dictionary is available. Information regarding assessment, diagnosis, management, complications, level of disability, and the presence of comorbidities relevant to UI/LUTS will be extracted. Study data will be extracted into and managed using the REDCap electronic data capture tool [ 40 ], hosted on a secure server at the Hunter Medical Research Institute, NSW.

Clinician Questionnaire

Our web-based clinician questionnaire is aligned with 13 of the 14 domains of the Theoretical Domains Framework [ 31 ] of behavior change. The optimism domain was not included as we perceived an overlap with the emotions, beliefs about consequences, beliefs about capability, and goals domain questions. Selecting domains to include in a questionnaire is in keeping with other studies that have used the Theoretical Domains Framework [ 31 , 41 ].

The target population for our intervention will be approached via email or in person by their site project team members and invited to complete a deidentified web-based questionnaire. Local site project team members will not have access to individual participant results. Demographic data will include age range, profession, and years of clinical experience. The clinician questionnaire was designed by authors KB, JD, and DM.

Process Evaluation

Measures will be collected to assess the process and fidelity of the implementation of the intervention. Spot check audits will be conducted by site members of the research team and site champions to identify any local issues with completing the SCAMP decision support tool. This information will inform local strategies to address the identified issues. We will also record the attendance for ward education sessions and the project team implementation workshops, the monthly project team meetings, the number and availability of identified champions throughout, the number and types of resources generated and reminder activities conducted, the number of audit and feedback sessions conducted, and any local changes made to the SCAMP intervention [ 42 ].

Economic Evaluation

As there are multiple potential benefits and the cost impacts are unclear from the perspective of the hospitals, we will undertake an exploratory assessment of resource use and costs and present these as a cost-consequences analysis [ 43 ]. We will obtain data on the costs of implementing the package (including staff training) and the direct health costs attributable to eligible patients across each study time period for the management of UI/LUTS, and report any potential cost offsets related to the practice-change package. Costs will be valued based on the reference year 2019. Data sources will include screening log and patient-level data from the medical record audits, hospital finance department data, research literature, expert opinion, and project management or administrative data. Costs and outcomes (ie, proportion of inpatients with an individually tailored UI/LUTS management plan and complication rates associated with UI/LUTS or urinary catheterization) will be presented to provide context for the changes in costs relative to the benefits to aid in the future translational potential of this package. All individual health and nonhealth effects of the intervention, including various cost items, will be reported as summary measures, for example, point estimates with a measure of variability ( Data Analysis section).

Sample Size and Power Calculations

For the primary outcome, 15 consecutive medical record audits per site per month (ie, a pooled sample of 675 audits anticipated per data collection period) will provide >90% power to detect a 10% absolute increase (from before intervention) in the proportion of incontinent patients with a continence management plan (type 1 error rate of 5%). This calculation conservatively assumes that 20% of patients in acute and 50% of rehabilitation sites have a plan before intervention (based on the Australian Stroke Foundation National Audit results for included sites [ 20 , 39 ]).

Data Analysis

The before-intervention group, after-intervention group, and maintenance period group results will be presented with descriptive statistics, including site, clinician, and medical record data for characteristics and demographics. No individual will be identifiable. All results will be presented as aggregated summary measures, with their variance depending on the distribution of the data (eg, mean and standard deviation, medians, and interquartile range). Groups will be compared with respect to change, from baseline (T 0 ) to immediately postintervention period (T 1 ) and from baseline to maintenance period (T 2 ) using mixed effects logistic regression models, with a random intercept for site, and fixed effect for period. Results are presented as odds ratios with 95% CI and P values.

Study Discontinuation

There are no criteria for study discontinuation as it is not anticipated that there are any events that would warrant discontinuation of this study. Any unforeseen adverse events will be reported to the Hunter New England Human Research Ethics Committee (the primary approval committee) and advice sought out regarding the required action. Any deviations from this original protocol will be reported in our study outcomes papers.

Preimplementation data collection (T 0 ) was completed in March 2020. As of November 2020, 87% (13/15) wards have completed implementation and are undertaking postimplementation data collection (T 1 ).

Our practice-change package is designed to reduce the current inpatient UI/LUTS care evidence-practice gap. We will contribute to the implementation research literature by demonstrating the potential impact of using a clinically applicable, evidence-based intervention that has been informed by the knowledge translation theory to optimize uptake in hospitals. We will describe the resources and costs associated with implementing the SCAMP intervention via a cost-consequences economic analysis. Our cost consequence analysis will provide an opportunity to pilot instruments used to collect economic data, such as resource use and clinical outcomes [ 43 ]. This analysis will be essential for establishing the benefit of scaling up the practice-change package. This study has been designed to provide clinicians, managers, and policy makers with the evidence needed to assess the potential benefit of further, wide-scale implementation of our practice-change package. We will report our findings according to the StaRI [ 24 , 25 ]. This will ensure that our practice-change package can be replicated in other clinical sites and in future research.

The results from this study will provide evidence to whether our UI/LUTS practice-change package is effective in supporting clinicians and health services deliver optimal care. To ensure that our practice-change package is evidence-based, clinically relevant, and applicable, it has been developed from the outset with our team of inpatient clinicians and managers, clinician researchers, and academics with experience in implementation science. To increase the generalizability and potential scalability of our practice-change package, we are testing it in a range of clinical scenarios and across the phases of inpatient care for people with a range of diagnoses, including stroke, admitted to metropolitan and regional hospitals in 4 health districts in 2 Australian states. It may also be applicable to other health conditions where providing optimal UI and LUTS care is challenging.

Acknowledgments

This research is being supported by the Hunter Stroke Service (Hunter New England Local Health District) and small project grants from the Hunter New England Local Health District Improvement Grant, NSW Agency for Clinical Innovation Research Grant Scheme, Priority Research Center for Stroke and Brain Injury (University of Newcastle), and NSW Nursing and Midwifery Strategy Reserve Funding. This funding has in no way influenced how the study was designed or will be conducted and reported. DC receives a Senior Research Fellowship from the National Health and Medical Research Council (1154273).

This study was approved by the Hunter New England Human Research Ethics Committee (HNEHREC reference no. 18/10/17/4.02) and co-registered with the University of Newcastle Human Research Ethics Committee (UON HREC reference no. H-2020-0083). The authors would like to acknowledge the following: the project team members who are not listed as authors: Hunter Stroke Service—Annalese Johnson; Port Macquarie—Emily Saul, Michelle Coad, Jeremy Mulder; Ryde Hospital—Soo Cho, Virginia Mapurazi, Helen Wheat; Coffs Harbour—Helen King; Rockhampton—Sandy Greensill; Wauchope—Catherine Williams; NSW Agency for Clinical Innovation—Kate Jackson (Stroke Network) and Louise Sellars (Rehabilitation Network); Monash University—Joosup Kim and Garveeta Sookram for assistance with the economic evaluation plan; and Hunter Stroke Service—Monique Hourn and Hunter Medical Research Institute—Alix Hall for assistance with Redcap.

Louise-Anne Jordan , who led the initial development of the SCAMP intervention in 2008 and played an integral part in this study protocol, sadly passed away in November 2019. The authors recognize her contributions, leading to her posthumous authorship.

Abbreviations

Authors' Contributions: DM, KB, DC, and JD led the overall development of the research protocol and DM led the development of the manuscript. L-AJ and M Pollack contributed to the development of the rationale and background for the protocol. JAD, JS, FM, AS, JB, SO, AB, KP, SL, MP, and KH contributed to the development of the protocol, intervention, and implementation support strategies. DM, KB, DC, and JD contributed to the development of data collection methods. DC contributed to the development of data collection methods and analysis specific to economic analysis. CO contributed to the study design, sample size calculation, and data analysis plan. JW provided the overall guidance for the proposed conduct. All authors have read and approved the final manuscript.

Conflicts of Interest: This project forms the basis of author KB’s PhD Candidature (University of Newcastle, NSW, Australia).

Urinary Incontinence

This module contains the following five sections:, (1) summary of content  , (2) powerpoint – urinary incontinence in older adults, (3) expert interview (podcast) –   “a discussion about dementia and urinary incontinence (ui)” , (4) case studies and discussion questions.

(5) Additional Resources  –  Instructor Notes, Presentation Handouts and References

Summary of content .

Urinary Incontinence (UI) is a problem experienced by many older adults and can have a profound effect on their lives.  Coping with incontinence can be challenging for older adults and their caregivers.  There are different types of incontinence and a variety of treatment options. 

This module includes an overview of the types of incontinence, assessment, diagnosis, and treatment.  The specific topic of older adults with dementia and incontinence and their caregivers is also addressed. 

POWERPOINT  

Expert interview , guest speaker biography:.

Nicole Davis, MSN, Ph.D. Candidate has worked for 11 years as a board certified Adult and Gerontological Nurse Practitioner and more recently as part of the Incontinence Clinical and Research Team in the Birmingham/Atlanta Geriatric, Research, and Clinical Center at the Atlanta Veterans Administration Hospital.  She has expertise in urinary incontinence, the needs of the aging, and using telehealth to assist senior caregivers in reducing their burden when caring for a family member with incontinence.  Ms. Davis has lectured and published on these topics.  She has also received several awards and funding for her work.  Ms. Davis is a National Hartford Centers of Gerontological Nursing Excellence Patricia G. Archbold Scholar, which recognizes her commitment and strong research agenda in gerontological nursing and urinary incontinence. Ms. Davis received her Master of Science degree in Nursing from Duke University and is currently a Ph.D. Candidate at the Byrdine F. Lewis School of Nursing and Health Professions, Georgia State University.

Ms. Davis’ dissertation is entitled “Using Telehealth to Support Informal Caregivers of Elders with Urinary Incontinence.”  Ms. Davis’ pilot research examines the possibility and practicality of a technology-facilitated, behavioral intervention that supports the caregivers of incontinent patients. The intervention provides the caregivers with UI management information and skill development in prompting the patient with incontinence to pass urine in a controlled fashion.  Finally, the intervention will supply the caregiver with individual telephone support from a nurse specializing in urinary incontinence. Ms. Davis hopes her pilot research will determine the impact of this intervention on the quality of life for patients and caregivers. 

Source:  http://nursing.gsu.edu/2014/01/10/ph-d-nursing-student-funded-ui-telehealth-research/  

Podcast Topic and Location:  

“a discussion about urinary incontinence and older adults”.

In this podcast, Nicole Davis, MSN, ANP, BS, GNP-BC discusses her experience in caring for older adults with Urinary Incontinence and Dementia and supporting family caregivers.  Podcast can be located within the powerpoint (above)- Slide #24  or by clicking below:

CASE STUDIES and DISCUSSION QUESTIONS  

Instructor Notes –   Instructor Notes – Urinary Incontinence in Older Adults

Presentation Handouts  –  Handouts – Urinary Incontinence in Older Adults

References –  References – Urinary Incontinence in Older Adults

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• Research article
• Open access
• Published: 20 April 2020

An evidence-based self-management package for urinary incontinence in older women: a mixed methods feasibility study

• E. Andrea Nelson 2 &
• Linda McGowan 3  

BMC Urology volume  20 , Article number:  43 ( 2020 ) Cite this article

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6 Citations

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Metrics details

Urinary incontinence (UI) is a distressing condition that limits women’s quality of life and places a heavy burden on health care services. Behavioural treatments are recommended as a first-line treatment. An evidence-based self-management package was developed following the Medical Research Council (MRC) framework for complex interventions. This study aimed to evaluate the feasibility and acceptability of the intervention.

A mixed-methods approach was undertaken, namely a randomised controlled feasibility study with nested qualitative study. Fifty women aged 55 or over living with UI, recruited from community centres were randomly assigned to either a 3-month course with the package with a support session or a control group to receive the same package only 3 months later. Principal outcome measures were: self-reported quality of life, UI severity, self-efficacy and psychological status. Analysis of covariance was undertaken to estimate within- and between- group changes for all outcomes. Acceptability was explored using individual interviews at follow-up.

Fifty women were randomised (24 to intervention, 26 to control); mean age of 69.7 (±9.1) years and mean UI frequency 2.2 (±2.2) episodes/day at baseline. Overall, 49 women (98%) completed 3-month follow-up (24 in the intervention, 25 in the control). A positive trend was detected in the impact of UI on their personal relationships (− 3.89, p  = 0.088), symptom severity (− 1.77, p  = 0.025), UI symptoms scale (− 1.87, p  = 0.031) and anxiety status (− 2.31, p  = 0.001), respectively. Changes in quality of life and self-efficacy did not differ significantly between groups. Majority of women (71%) in the intervention group reported subjective improvement after 3 months. Spearman correlation coefficient was 0.43 ( p  < 0.05) between their subjective perception of change and self-efficacy. Women perceived the package being acceptable and described that the package had the potential to increase their knowledge and confidence to manage symptoms and improve quality of life.

Conclusions

The study demonstrated that the self-management package is feasible and acceptable for older women with UI. Further studies are needed with a large sample size in clinical settings to evaluate the effectiveness of this package.

Trial registration

ISRCTN17194896 . Registered on 11th September 2019 (retrospectively registered).

Peer Review reports

Urinary incontinence (UI) is a distressing condition that limits people’s quality of life and places a burden on those affected and health and social care services [ 1 , 2 ]. Prevalence in women is estimated to be around about 40%, with an increase with age [ 3 ]. Women living with UI often experience functional limitations and social embarrassment, negatively impacting their mental health [ 4 ]. Although several options are available for treating and managing UI, behavioural treatments are recommended as a first-line treatment therapies for stress, urgency and mixed UI by international UI guidelines developed worldwide [ 5 ], prior to considering more intensive treatments.

Behavioural treatment programmes focusing on single elements of behavioural strategies have been extensively researched, e.g. pelvic floor muscle exercises (PFME) [ 6 ]. These programmes are sometimes challenging to deliver as they need multiple appointments, the involvement of specialised practitioners, and may lack flexibility to respond to individual needs associated with comorbidities in older women. Many women therefore choose to disengage with the service. Only a third of women with UI consult a doctor in European countries such as France, Germany, Spain and the UK, and 20 to 25% of those experiencing significant clinical symptoms seek care and less than half of them receive treatment [ 7 ]. A multifaceted intervention involving behavioural strategies may be more effective than a single component for the management of UI in older women [ 8 , 9 ].

Self-management for chronic conditions is multidimensional and defined as an intervention designed to develop individuals’ knowledge, skills or psychological and social resources and their ability to manage their health condition and consequences, through education, training and support [ 10 ]. Many self-management interventions have been developed to support people to cope with their health conditions and improve quality of life. Positive outcomes reported include a higher degree of self-efficacy, reduced physical interference, and improved mental health status at follow-up [ 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 ]. Although evidence for self-management programmes incorporating multifaceted behavioural treatments for use in UI among older women is currently limited, our systematic review concluded that multifaceted self-management interventions including PFME, bladder retraining, or combination behavioural techniques are beneficial.

Following the Medical Research Council (MRC) framework for developing and evaluating complex interventions [ 22 ], a self-management package was co-developed with older women with UI and health professionals providing treatment and care. The initial draft of the intervention was informed by synthesis of data from a systematic review and stakeholder interviews with women and health professionals. Both groups preferred an evidence-based self-management package that had the capacity to meet women’s individual needs with the flexibility to modify behaviours in coping with UI without significant service provision and/or intensive interaction with health professionals. The initial draft was reviewed and discussed in detail with an expert group which consisted of four women with UI, five health professionals and two lay members. Consensus was reached on the content and format of this self-management package for older women with UI using a normal group technique [ 23 ]. However, the feasibility and acceptability of the intervention remained unknown.

The aim of this study was to evaluate the feasibility, acceptability, and preliminary outcomes of an evidence-based self-management package for UI in older women. Specifically, it was to 1) assess the feasibility of the intervention to evaluate the effectiveness of a self-management package; 2) assess the variation of the main outcome measures to inform sample size considerations for a full randomised controlled trial (RCT); 3) provide preliminary data on the effect of the intervention; 4) understand the benefits/limitations and acceptability of the self-management package compared to no active treatment.

A mixed-methods approach comprising a two-arm RCT feasibility study with a nested qualitative study was undertaken. The qualitative study was conducted to understand how the intervention might work and explore facilitators and barriers to acceptance of the intervention [ 24 ]. This study presented adheres to CONSORT guidelines.

Patient and public engagement

A project advisory group comprising three older women (aged 55 plus) living with UI and one nurse working in a community continence clinic was set up prior to the commencement of this study, to ensure this study addressed issues that were important and relevant to women. The meeting was led by YF and facilitated by LMc/EAN every 6 months. Participants were provided with background information and clinical guidelines for UI management and consulted for their current experiences and expectations of managing UI. They also reviewed the findings of the systematic review and interview transcripts. All highlighted the need for evidence-based practice that has the ability to engage the wider population and indicated a willingness to use it for UI self-management. The group also supported the application of ethics approval and development of interview schedules.

This is a single-centre, randomised controlled feasibility study of self-management package versus wait-list control with 12- week post-intervention follow up. Participants were recruited using flyers posted in community centres of a local Forum for older people in West Yorkshire, UK. A short presentation was also given by the project researcher in most centres.

Participants

Women were eligible if they were aged 55 or over, had self-reported symptom of involuntary leakage of urine and were able to read and speak English. Individuals who self-reported their UI were caused by neurological diseases affecting the brain and spinal cord, or were cognitively impaired were excluded.

A consecutive sampling strategy was applied to recruit participants in this study. Assuming an attrition rate of 20%, a target of 25 per arm was sufficient to have 20 participants in each arm by the end of the study. This has been recommended as acceptable for a feasibility trial assuming at worst a medium effect size (Cohen’s d = 0.2) for a continuous outcome and 80% power [ 25 ].

Randomisation

All participants were recruited prior to randomisation to the intervention. Eligible women were randomised using a 1:1 ratio to either the intervention or control group. The randomisation procedure was performed by a web-based randomisation service ( https://sealedenvelope.com/ ). Due to the nature of the intervention, this study is considered open-label and is not allocation concealed because the researcher delivering the interventions and the participants were aware of group allocation at the time of implementation.

Intervention

The experimental intervention was the self-management package, co-developed with older women living with UI, health professionals and lay members. The aim of the package was to provide information and practical skills for women to self-manage their UI and other symptoms. Following elements were included: recognition and awareness, getting the support you need, understanding the cause, learning to manage your UI, developing a self-management plan and how can you find out more. Descriptions of self-management techniques such as PFME, bladder training and lifestyle interventions were also provided. The researcher acted as a facilitator and delivered the intervention in person immediately after the completion of baseline data collection. A self-management brochure was also distributed. The intervention group could request a single one-hour support session with the researcher if they had any difficulties in using the package.

The control group did not receive the self-management package or the support session. However they had been given a copy of the same package upon the completion of their follow-up data collection (at 3 months).

Outcome measures

As this was a feasibility study it was appropriate to explore a range of outcome measures. Standardised self-reported measures were used to assess participants’ generic and disease-specific quality of life, UI severity, self-efficacy and psychological health respectively: the EuroQol (EQ-5D-5 L) [ 26 ], King’s Health Questionnaire (KHQ) [ 27 ], International Consultation on Incontinence Questionnaire – urinary incontinence short form (ICIQ-UI SF) [ 28 , 29 ], Geriatric Self-Efficacy index for urinary incontinence (GSE-UI) [ 30 ], and Hospital Anxiety and Depression Scale (HADS) [ 31 ]. Data were collected at baseline and three-month follow-up. Patient Global Impression: Improvement (PGI-I) was obtained from the intervention group only at three-month follow up [ 32 ]. These measures have been commonly used in research and practice for women with UI.

Data analysis

Descriptive analyses were undertaken to establish recruitment, drop-out rates and the distribution of baseline and follow-up characteristics and outcomes. For each of the above measures, analysis of covariance (ANCOVA) was conducted adjusting for their baseline values to take account of outcome imbalance at baseline and estimate the impact of intervention compared with control [ 33 , 34 ]. T-tests and Chi-square tests were applied to compare two groups at baseline and follow-up for continuous and categorical variables, respectively. Intention-to-treat analysis was performed for this study. Data from all subjects were included in the analysis as randomised. To test the appropriateness of the analysis, complete case analysis was undertaken for each of the above outcome measures to identify the relative treatment effects using a linear (for continuous variables) and logistic (for binary outcomes) mixed model. For all analyses, a two-tailed p -value less than 0.05 was considered statistically significant and a p-value between 0.05 and 0.1 was interpreted as indicating a trend [ 35 , 36 ].

Nested qualitative study

Women in the intervention group were eligible to participate in this subsequent qualitative study aiming to understand the acceptability of the package. They were purposively recruited considering different types of UI, number of years living with UI, to enable wider discussions on the self-management package and their experience. The concept of data saturation guided sample size for this qualitative study [ 37 ].

Semi-structured individual interviews using open-ended questions were undertaken at follow-up. Interviews were conducted either face-to-face in the participants’ homes, in a meeting room at the University, or by telephone, based on participants’ preferences. Interviews were digitally recorded with permission and transcribed verbatim for analysis. Interviews focused on exploring participants’ experience of managing symptoms guided by the intervention, facilitators and barriers to the use of the package, comments on the content and format, feedback on outcome measures used and suggestions on dissemination strategy.

Data analysis was commenced during the interview phase and the transcription, and continued during the analysis of the transcriptions, hence early commencement of analysis facilitated the development of subsequent interviews [ 38 ]. Data were analysed using thematic analysis [ 39 ], involving a six-step procedure: familiarising the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report. Although they were presented as a step-by-step procedure, the analysis was an iterative and reflexive process to finalise the themes. To ensure trustworthiness and rigour of the analysis, we double coded the data as a validity check and explored alternative interpretations of the data and through discussion with members of the research team. Interview transcripts were managed and analysed using Nvivo, a qualitative software programme for organising and coding the data [ 40 ].

Participants characteristics

Overall 50 participants ( M age =69.7, SD  = 9.1), were randomly allocated to either intervention ( n  = 24, M age =69.5, SD  = 8.9) or control group ( n  = 26, M age =69.8, SD  = 9.5). During the 3 months follow-up, no one in the intervention group requested the support session with the researcher. One woman in the control group dropped out due to admission to the hospital for other health conditions. A total of 49 participants with a mean age 69.6 (SD = 9.1) were included in the complete case analysis. No significant differences were found for all demographics and UI characteristics collected at baseline, indicating that randomisation was achieved between the intervention and control groups. The majority were white British (77.6%), completed secondary and higher education (91.8%), were retired (71.4%), and had delivered 2 or more children (71.5%). The number of participants was similar across different UI types. Please see participant’s characteristics in Table  1 .

Medians, interquartile range (IQR), mean, standard deviation (SD) and p -values of all baseline and follow-up outcomes are shown in Tables  2 and 3 , respectively. There were no differences shown in general quality of life, UI symptoms scale and emotional health status at baseline, however groups differed with regard to KHQ severity measures (34.03 vs 48.67, p  = 0.028) and self-efficacy (84.96 vs 57.76, p  < 0.001). At follow-up, differences were detected in KHQ symptom severity (6.38 vs 9.04, p  = 0.006), UI symptoms scale (5.38 vs 7.76, p  = 0.022), self-efficacy (89.13 vs 69.08, p  = 0.007), and anxiety (5.13 vs 7.80, p  = 0.049) at 3-month follow-up.

The effect of the self-management intervention on outcome measures between intervention and control groups were demonstrated in Table  4 . The difference captured on each outcome measure was further shown in Figs.  1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 and 9 , respectively. Participants’ general quality of life were improved within both groups after the follow-up, however no significant difference was identified (see Figs. 1 and 2 ). Similarly, no difference was shown in UI specific quality of life (see Figs.  3 and 4 ), self-efficacy (see Fig.  7 ), or depression status (see Fig.  9 ) between groups. However, significant differences were detected in participants’ KHQ symptom severity (− 1.77, p  = 0.025; also see Fig.  5 ), ICIQ-UI SF symptoms scale (− 1.87, p  = 0.031; also see Fig.  6 ), and their anxiety status (− 2.31, p  = 0.001; also see Fig.  8 ), respectively. A positive trend was also observed in the participants’ KHQ personal relationships (− 3.89, p  = 0.088; also see Fig.  4 ).

Mean (95 and 90% confidence intervals) of pre-post intervention differences and treatment effect for EQ-5D

Mean (95 and 90% confidence intervals) of pre-post intervention differences and treatment effect for EQ-5D utility and VAS scores

Mean (95 and 90% confidence intervals) of pre-post intervention differences and treatment effect for KHQ, Part I

Mean (95 and 90% confidence intervals) of pre-post intervention differences and treatment effect for KHQ, Part II

Mean (95 and 90% confidence intervals) of pre-post intervention differences and treatment effect for KHQ, Part III

Mean (95 and 90% confidence intervals) of pre-post intervention differences and treatment effect for ICIQ-UI SF

Mean (95 and 90% confidence intervals) of pre-post intervention differences and treatment effect for GSE-UI

Mean (95 and 90% confidence intervals) of pre-post intervention differences and treatment effect for HADS, Anxiety

The relationship between the participants’ perceived improvement and the difference in outcomes within the intervention group was assessed using Spearman correlations (Table  5 ). There was a significant correlation shown between PGI-I and GSE-UI ( r s = 0.43, p  < 0.05). Mean change in GSE-UI for participants who responded “better” on the PGI-I were significantly higher than those who responded “no change” or “worse”.

Qualitative findings

Individual interviews were undertaken with 15 participants from the intervention group at their homes. Participants ranged in age from 55 to 86 years. The majority were retired (11; 73%) and had suffered from UI for more than 5 years (11; 73%), but had received no support (13; 87%) from health services.

Each interview lasted between 15 and 48 min. A total of four themes were generated. Facilitators and barriers to the use of the self-management package followed by suggestions were also explored under each theme.

Raising awareness and gaining/refreshing knowledge

All participants found that this package had raised their attention to UI management as well as the resources and support available. Some participants learned new knowledge and management skills, while others found it useful to help refresh their memory. Positive comments were received on the fact that this package gathered both information and practical skills in a systematic and structured manner, accompanied by tips shared by women and health professionals.

“Yeah, I found the information on how to do the pelvic floor muscle exercises really good, it describes exactly what you should do and how much you should do..” (W5)

A few participants also expressed the need for more detailed information and tips to meet their needs. For instance, information and explanation were desired for biofeedback, vaginal cones, pads and how certain lifestyles impacted on UI symptoms and severity. In addition, some participants shared strategies and experiences of managing UI, including yoga, weight management programmes, and using reminders to practice PFME.

Half of the participants also identified the bladder diary as a potential barrier to the use of this book. For people who were in employment or regularly involved in outdoor activities, they felt that it was difficult and infeasible to measure intake of fluids and volume voided.

Feeling more confident and motivated to management UI

Participants generally felt more equipped and confident in managing their UI with resources and support supplied in the package.

“…we can do this, at least we know where to contact, we can tell the doctors also but if it happens to somebody you can tell them and they can do this.”(W24)

Participants also expressed their desire to motivate for self-management, however many of them did not practice as much as they would like to due to other commitments. Hence they suggested the inclusion of information and strategies on how to stay motivated and develop adherence.

“I suspect a lot of people would read the book, and think, oh yeah, that’s a really good idea, I ought to be doing that, and then never, ever actually do it.”(W46)

Being a useful and user-friendly package

All participants preferred the fact that this package was colour coded, making it easy to read and follow. They found the texts being easy to read and understand and the illustrations being appropriate, indicating that there was no need to book the support session. Some participants described benefit gained as a result of using this package.

“The book was very well put together, and very clear, very easy to read, and it was very informative.” (W6)

“I’m still having the occasional accident, but now I’m sort of going oh well, I will get there. It’s not a major setback. But it’s not affecting my life like it used to.” (W5)

Some of them preferred a smaller size of the package so they could carry in their handbags, whereas some believed that people tended to put it away if it was a small book. A few concerned about the phrase “older women” used in the title of the package and suggested to remove it or simply indicate “women over 55”.

Exploring dissemination strategies

All participants found the self-reported questionnaires in the feasibility study acceptable and considered them being necessary. Some appreciated being involved in this study. All participants recommended places where appropriate to distribute the package, including doctor’s surgeries, hospitals, pharmacies, workplaces, public libraries, local leisure centres, and other meeting places for women.

Some participants also expressed the need to design the package in multiple languages groups who may have limited access to support and resources. In addition to delivering the package to individuals, a couple of participants expressed their preference for a group to enable peer support.

This results of this study provide supporting evidence for the feasibility and acceptability of the self-management package as a complementary strategy for the management of UI in older women. This results of the feasibility RCT have confirmed that recruitment of women with UI from local community centres who were not actively engaged with health services is feasible and the drop-out rate is low. Completion and follow up of the questionnaires were successful. The findings of the acceptability study have suggested that the package may be a useful resource in improving women’s knowledge and practical skills for the management of UI. Women also expressed the need for such intervention for this condition and commented that questionnaires used to capture information were acceptable.

The feasibility RCT showed that women’s UI severity, symptoms and anxiety status were improved after the intervention for 3 months. This provides initial evidence that this self-management package has the capacity to reduce both physical and emotional impact of UI on women. There is an increasing interest in the self-management of UI consisting in both research and practice, however many interventions only focused on one particular skill or technique [ 6 ]. The UK Continence Society has recommended a support package for patients with UI as a minimum standard for continence care [ 41 ]. With no evidence-based package being available, this study developed the intervention consisting of multiple components and also demonstrated the acceptability of the intervention and potential benefit on women’s physical and psychological health. Therefore, future studies are needed to evaluate the intervention in other settings in a larger multicentre trial in order to gain robust evidence.

Although the difference in women’s quality of life or self-efficacy was not detected, women described that they felt more confident and motivated to self-manage their condition and some of them gained improvement after using the package. Qualitative interviews further supported these findings and participants reported that the package was informative and useful in raising their awareness. A significant correlation was observed between women’s self-efficacy and their subjective perception of improvement. This suggests that women who gained a higher level of self-efficacy were likely to experience an improved subjective perception of their UI condition. Therefore, individual’s self-efficacy level needs to be assessed as a way to stratify participants before randomisation process. For those with extremely low self-efficacy, interventions with a purpose to build their confidence may be needed before providing self-management package.

Existing literature has shown modest benefit of self-management interventions in older women with UI. Compared to pharmacological therapies alone, nonpharmacological interventions, such as behavioural therapy either alone or combined with other intervention, are more effective in achieving cure or improvement both stress and urge UI [ 42 ]. Clinical effectiveness of self-management of UI has also been with respect to symptoms, UI severity, quality of life and perceptions of improvement when being delivered in group format with effects maintained (12 months [ 43 ]. Similarly, this study has observed improvement in symptoms and severity with the self-management package, and effects on psychological health. This package appears feasible to modify women’s quality of life living with UI. Further studies may be needed to investigate the effectiveness of self-management interventions on both physical and psychosocial outcomes in women with UI, at both short and long term.

Strengths and limitations

The intervention was co-developed with key stakeholders including women with UI and health professionals. The feasibility and acceptability of the intervention were evaluated with women who were not actively engaged with clinical services for UI. Potential positive effects were observed in women’s UI symptoms and their psychological status, which were further supported by the women’s experiences. However, careful interpretation is needed. The study was not allocation concealed and the sample size was not sufficiently powered to make robust inferences about the effectiveness of the intervention. Further studies are needed with a large sample size in multiple clinical settings to evaluate the effectiveness of this package. There is a possibility of bias associated with the self-reported measures. Objective information such as pad test or measure of PFM strength may be needed. It is worth noting that pad tests are not recommended in the routine assessment of women with UI by the NICE [ 44 ]. Also, women may be less in favour of the invasiveness of the measures such as vaginal dynamometer.

The self-management package consisting of multifaceted behavioural techniques appears feasible to improve UI symptoms, severity and anxiety status in older women living with UI. Women also found it useful for increasing their awareness, motivation and knowledge of UI management. This study suggested that this package has the potential to be implemented in routine practice with further evaluation of effectiveness in clinical settings.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Medical Research Council

Pelvic floor muscle exercises

• Randomised controlled trial
• Urinary incontinence

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Acknowledgements

We thank women and health professionals’ involvement and their contribution to this study.

This work was supported by Leeds Benevolent Society for Single Ladies (LBSSL) at UK, a Charitable Incorporated Organisation (registered charity number 1155794). The funder had no role in the design of the study, collection, analysis and interpretation of data, the views expressed are those of the authors and not necessarily those of the LBSSL.

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Fu, Y., Nelson, E.A. & McGowan, L. An evidence-based self-management package for urinary incontinence in older women: a mixed methods feasibility study. BMC Urol 20 , 43 (2020). https://doi.org/10.1186/s12894-020-00603-8

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A Review and Case Study of Urinary Incontinence

Emily Bagnola 1 , Edward Pearce 1 , and Barbara Broome 2*

1 Honors Nursing Student, College of Nursing, Kent State University, Kent, Ohio, USA 2 Dean and Professor, College of Nursing, Kent State University, Kent, Ohio, USA

*Corresponding author: Barbara Broome , Professor of Nursing, Kent State University, USA, E-mail: [email protected]

Received: April 04, 2017 Accepted: April 07, 2017 Published: April 12, 2017

Citation: Bagnola E, Pearce E, Broome B. A Review and Case Study of Urinary Incontinence. Madridge J Nurs . 2017; 2(1): 27-31. doi: 10.18689/mjn-1000105

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Urinary incontinence (UI), the involuntary leakage of urine due to the loss or weakened control of the urinary sphincter, is a crucial subject of medicine that has physiological, psychological, and sociological complications [25] . Urinary incontinence can range from mild leakage to an overflow amount of urine. Although this is a common problem affecting millions of Americans, it is not often a subject of discussion because it can be embarrassing for people to talk about, even with their physicians [2] . Physiologically unpleasant for patients, UI can also be emotionally demeaning, decreasing self-concept and perceived body image. UI can be divided into transient (acute) incontinence and chronic incontinence; they both have significant effects on the patient despite one lasting longer than the other. Causes of incontinence can originate from a variety of causes. Research indicates urinary incontinence may be related to genetic factors, biological aspects, and physiological characteristics [14] . Treatment for incontinence includes behavioral, pharmacological, and surgical interventions, as well as catheterization. Appropriate treatment is based the individual's current situation and follows evaluation of which treatment option will provide the best opportunity for the highest quality of life.

Keywords: Urinary incontinence; Self confidence; Genetic factors; Biological aspects; Physiological characteristics.

Urinary incontinence (UI) is the involuntary leakage of urine. Urine is stored in the bladder, which is relaxed when a person is not urinating. When a person urinates, the bladder muscles constrict, thus forcing urine into the urethra, a tube that acts as a passageway to connect the urinary bladder and the external part of the body. During this process, the muscles around the urethra relax, allowing the urine to exit from the body. Urinary incontinence occurs when the muscles around the urethra relax involuntarily [3] .

Urinary incontinence can be classified into two categories: transient or chronic. Transient incontinence is a temporary, reversible, or acute type of incontinence. An illness or medical condition that is short-lived causes transient incontinence. Once the illness or condition is treated, the incontinence is treated by default. The other category of incontinence, chronic incontinence, consists of five different types: stress, urge, mixed, overflow, and functional [14] . Stress incontinence, the most common type of urinary incontinence in women, occurs when there is a loss of urine during physical activity or exertion such as coughing, sneezing, laughing, exercise, or any other movements which put pressure on the bladder [3 , 32] . Urge incontinence, often called overactive bladder, is the sudden need to urinate due to increased intra-abdominal pressure or spasmodic activity of the bladder. A person with overactive bladder feels urgency and may leak before reaching the restroom. This commonly occurs while a person is sleeping, drinking water, looking at water, or touching water. When a person experiences symptoms of both stress and urge incontinence, it is referred to as mixed incontinence [7] . When a person cannot completely empty their bladder while urinating, it is referred to as overflow incontinence. A common symptom experienced by a patient with this type of incontinence is “dribbling” after urination. Functional incontinence is a category of incontinence that is related to a mental or physical disability. While a patient might have a healthy urinary system, their disability impairs the ability to get to the restroom [37] .

UI has a variety of systemic causes, including urinary dysfunction; neurological, musculoskeletal, and pharmacological issues; nutrition; genetics; and individual health. These areas of causation can produce symptoms that are both acute and chronic. Acute causes of urinary incontinence are generally observed to be short-term, and once these underlying conditions are treated, UI usually disappears. Within the urinary system, common causes of acute UI include prostate infection/inflammation, urinary tract infection (UTI), and stool impaction [19 , 22 , 24 , 27 , 29 , 32] . An enlarged prostate or prostatic hypertrophy may cause infection and/or inflammation resulting in UI. The prostate is located just below the bladder and surrounds the urethra. Prostate enlargement can narrow the urethra, resulting in incomplete and delayed emptying which can result in a urinary tract infection (UTI). UTIs are infections of the bladder or the urethra. Although women are more prone to UTIs than men, UTIs are worrisome and related to infection in the bladder. UTIs cause the patient to feel the need to urinate more than usual or can make the individual feel as though he or she cannot empty their bladder completely [24] .

Constipation may also cause UI. The rectum and the bladder share many of the same nerves [19] . When constipation occurs and there is bulk in the rectum from stool, the nerves can be over stimulated, resulting in an increased feeling of the need to urinate [19 , 32] . Other causes of UI are the shortterm nervous complications from alcohol or sedative drug withdrawal, drug abuse, electrolyte imbalances, infections, poisons, or surgery after which patients may experience mental confusion [12] . This type of confusion or delirium can result in situation-related UI [19 , 3] . Another common cause of UI is medications. Pharmacological agents, such as diuretics, antidepressants, cough and cold remedies, antihistamines, angiotensin converting enzyme (ACE) inhibitors, hormone replacement therapy, and sedatives can cause temporary incontinence because they alter the natural storing and passing of urine [24 , 32] . For example, in the renin-angiotensinaldosterone system in the genitourinary tract, ACE inhibitors prevent angiotensin I from being converted to angiotensin II, a vasoconstrictor which treats hypertension. ACE inhibitors also cause a decrease in urethral sphincter tone [8] .

Nutrition and certain foods and drinks may mimic the effects of diuretic medications, including alcohol, caffeine, tea, coffee, carbonated drinks, artificial sweeteners, corn syrup, and foods high in spice, sugar, acid, and vitamins B and C [32] . Nutritional factors can also change the pH of urine. The pH of urine ranges from 4.5-8 with the average pH being about 6, indicating that urine is slightly acidic [21] . An increase in consumption of certain vegetables, citrus fruits, and meat can lower the pH of urine, thus making it more acidic. Acidic urine can cause bladder spasms, leading to UI [11] . Lastly, the overall health of the individual can play a key role in acute UI, including the patient's weight and pregnancy status, which both cause increased intra-abdominal pressure [24] .

As opposed to acute causes of urinary incontinence, chronic causes are not as easily reversible and have a longer duration. Chronic causes of UI are directly involved with the urinary system, including untreated benign prostate hyperplasia (BPH), bladder cancer, bladder fistula, bladder spasms, and bladder stones. BPH is an enlarged prostate. The prostate is a gland in men located between the penis and the bladder. If the prostate gland becomes enlarged, it can put pressure on the bladder. A tumor from bladder cancer can cause overflow incontinence if the tumor blocks the urethra. Often, the treatment of bladder cancer also lead to UI because radiation or surgery to remove the tumor can cause damage to the urethra. A bladder fistula is a connection formed between the vaginal wall and the bladder. The body forms a fistula when there is a block, typically from an obstruction during childbirth. UI is a consequence because urine bypasses the urethra and exits out the vagina. Bladder stones form when the urine becomes too concentrated with salts. These mineral stones can block the ureter, thus causing UI [24 , 38] .

Several neurological conditions, including Alzheimer's disease, depression, multiple sclerosis (MS), stroke, Parkinson's disease, and certain spinal cord injuries may cause chronic UI as well [24] . Alzheimer's disease is a common form of dementia. Those who suffer from Alzheimer's lose mental functions such as memory and judgment. This loss of mental function can affect the ability to control the bladder. Depression and UI can go hand-in-hand. If a patient is depressed, he or she may be less likely to seek treatment for UI. Patients who experience UI may become depressed due to embarrassment. MS affects the nervous system. It can interfere with the nerve signals that help with the movement of urine. Therefore, urine might come out from the body before the patient is ready. A stroke can lead to muscle weakness, specifically around the bladder. Loss of muscle function around the bladder could cause UI. Parkinson's disease is a disorder that affects the nervous system. UI may result from Parkinson's because the brain does not communicate with the sphincter. As a result, the sphincter opens and releases urine when there is only a small amount. Damage to the spinal cord also disrupts communication from the brain to the sphincter [24] .

From a musculoskeletal standpoint, connective tissue disorders and sphincter weakness can also affect continence. Connective tissue disorders can have long-term effects on UI because the connective tissue around the bladder is weaker [24] . Ehlers-Danlos syndrome is a connective tissue disorder that causes lax skin and hyper mobile joints. The organs, such as the bladder, can also become lax, and this condition may lead to the bladder dropping from its normal position and pushing against the vagina. This is known as pelvic prolapse, and UI can be a common side effect [31] . Spinabifida can cause sphincter weakness. Spinabifida is a condition in which the spinal cord does not develop properly, which may cause varying degrees of paralysis [9] . This can cause immobility, the leading factor for functional incontinence.

The nutritional intake of an individual can also have longlasting effects on urinary incontinence, such as persistent, poor fluid intake. If an individual is lacking proper fluid intake, his or her urine will eventually become concentrated. Concentrated urine irritates the bladder because it changes the pH of urine. The urine becomes more acidic, which leads to an over active bladder. Based on the individual, certain health and genetic factors play a significant role in urinary incontinence, such as age, menopause, and various birth defects [24] . Ectopic ureter is a birth defect where the ureter does not terminate in the urinary bladder. Due to this structural abnormality, UI is a common consequence. Other types of birth defects include urethral duplication and ureterocele. Urethral duplication is when two ureters enter the bladder on the same side. This can cause the urine to back up into the kidneys.

Ureterocele is swelling at the bottom of the ureter which blocks the flow of urine. These birth defects may lead to UI due to the improper flow of urine [9] .

Much like the causes and risk factors, treatments of urinary incontinence can be categorized as behavioral, pharmacological, catheter, or surgical. The simplest example of a behavioral treatment is lifestyle change by the patient, such as monitoring consumption of fluids, quitting smoking, and losing weight. Another example of behavioral treatment is bladder training, where the goal is to increase the amount of time between emptying the bladder and the amount of fluid the bladder can contain. In order for bladder training to be successful, the patient must adhere to a strict voiding schedule, even if he or she does not feel the need to urinate. Another crucial aspect of bladder training is pelvic floor muscle exercises, commonly called Kegel exercises, which are non-evasive exercises that help strengthen the pelvic floor muscles. Pelvic floor muscles support vital organs that affect elimination, including the uterus or prostate, bladder, small intestine, and rectum. Men and women may both benefit from Kegel exercises.

The first step in Kegel exercises is for the patient to determine which muscles he or she needs to exercise in order to be effective. Stopping urination midstream helps to identify the muscles, but one common mistake that patients make is concentrating on the abdomen, thighs, and buttocks, which are not part of the pelvic floor muscle group. An instrument called a biofeedback mechanism can help a patient identify the correct muscles [20] . According to the UCSF Medical Center (2017a), a biofeedback mechanism uses computer graphs and audible tones to show which muscles the patient is exercising and the strength of those muscles [36] . Once the patient has successfully identified which muscles are effective, they should perform these exercises about three times a day while standing, sitting and lying down and not during urination [11] . The nurse's role in patient teaching is crucial, as the nurse will assist the patient in developing the skill to perform Kegel exercises. Kegel exercises are used to increase pelvic muscle strength to treat stress, urge, and mixed incontinence. Other strategies include “quick flicks” for urgency and bladder training. If the patient has to urinate before the scheduled time, he or she should use Kegel exercises to suppress the urge to urinate. Bladder training starts at small intervals and then can be increased to 30-minute increments once a goal is met. This continues until the patient is able to comfortably last for four hours without urinating [37] .

Another common form of treatment is the use of pharmacologic agents, specifically anticholinergic medications. Anticholinergic drugs block acetylcholine (Ach), a neurotransmitter common in the parasympathetic nervous system. One common function of Ach is to send signals to the brain that trigger bladder contraction. Common types of anticholinergic medications prescribed for urinary incontinence include: Oxybutynin (Ditropan XL, Oxytrol), Tolterdoine (Detrol), Darifenacin (Enablex), Solifenacin (Vesicare), Trospium (Sanctura), and Fesoterodine (Toviaz).Another type of medication used for UI is Mirabegron (Myrbetriq), which relaxes the bladder muscle and can increase the amount of urine that the bladder can hold before having to urinate [18] . Alpha-blockers and 5-alpha reductase inhibitors are common medications that are prescribed for men. Alpha-blockers, such as Terazosin (Hytrin), Doxazosin (Cardura), Tamsulosin (Flomax), Alfuzosin (Uroxatral), and Silodosin (Rapaflo), can help treat prostate enlargement and bladder obstruction complications by relaxing the smooth muscle in the prostate and bladder [26] .

As reported by the National Institute of Diabetes and Digestive and Kidney Diseases, 5-alpha reductase inhibitors, like Finasteride (Proscar) and Dutasteride (Avodart), block the production of dihydrotestosterone, a male hormone that can accumulate in the prostate and cause prostate growth. The blocking of dihydrotestosterone helps shrink an enlarged prostate and can help treat UI [26] . Lastly, in 2011 the FDA approved OnabotulinumtoxinA(Botox) for the treatment of urinary incontinence related to spinal cord injury, multiple sclerosis, or other nervous system disorders. These injections work by blocking the action of ACh and paralyzing the bladder muscle [16 , 18] . However, it is important to remember the side effects of these medications. Many individuals with comorbid health conditions may not be able or willing to take these drugs. For example, patients with hypertension should avoid Mirabegron because it can increase blood pressure [1] . Those who have glaucoma may not take anticholinergic drugs due to their effect of dilation of the pupils [16] . Anticholinergics and alpha blockers may cause tachycardia; therefore, patients who suffer from cardiovascular disease should avoid these medications [4 , 16] . Furthermore, 5-alpha reductase inhibitors may cause sexual dysfunction. Men may also experience a side of effect of impotence. Pregnant women should avoid all of these medications due to their possible effects on the fetus [34 - 36] .

A form of treatment that is widely used in the medical field today is the use of a catheter. Catheters are thin, flexible tubes that are inserted into the bladder through the urethra to drain the bladder [26] . Catheters can be inserted in the bladder through the urethra, a procedure referred to as an indwelling or Foley catheter, or an incision can be made in the abdomen where the catheter is then placed in the urethra, a suprapubic catheter. Catheters have many advantages. For example, a catheter may be used for both long-term and short-term use. Inserting a Foley catheter is not difficult once a person is trained in the procedure [28] . Ahealth care provider may teach an individual how to self- catheterize [32] . This type of catheterization is called intermittent catheterization. Having a patient insert their own catheter can help improve self-care and independence. Individuals who perform self-catheterization have a reduced risk of infections due to normal flora. Normal flora are the non-pathogenic bacterium that act as barriers to infection. Patients who perform self-catheterization have healthier flora because they do not leave their catheter in as long as an indwelling catheter, and they can regularly clean their skin when the catheter is not in place [23] .

Indwelling catheters are cost effective compared to other treatments of UI. However, catheters should not be the first choice when attempting to control UI. Catheters have many risks factors. Urinary catheters can cause urinary tract infections (UTIs). In fact, catheters are the number one cause of UTIs. According to the Journal of Community Nursing , urinary catheters can also cause “urethra trauma, urethral stricture formation/perforation in addition to other complications such as encrustation, bladder calculi and neoplastic changes” [17] . In addition to these physical risk factors, urinary catheters can also lead to changes in a patient's sex life. Indwelling catheters should be removed before intimacy takes place, which may cause embarrassment [28] .

Lastly, patients may always opt for surgery to correct their urinary incontinence. Injecting bulking agents into the urethra is a procedure which may be effective for both men and women. A bulking agent, usually collagen, is injected into the tissues surrounding the urethra. This helps the urethra close tightly and keeps urine from leaking out. However, this procedure is not suitable for people who are allergic to collagen [10] . The two most common types of procedures for urinary incontinence in women are sling procedures and suspension procedures. According to the Mayo Clinic (2008), a sling procedure typically uses mesh to create a supportive sling under the urethra, which keeps the urethra closed. Suspension procedures require stitches to keep the bladder and urethra from sagging [20] . The most common type of surgical procedure for UI is the Mid urethral sling in which thin strips of mesh tape are inserted through a vaginal incision to reinforce the urethra. However, many women do not want to use mesh and often prefer the bladder neck sling because it uses the patient's own tissue to make the strong sling.

If the patient is experiencing prolapse of other pelvic organs, a surgeon may recommend Burch colposuspension. This type of surgery involves the surgeon opening the lower abdomen and placing stiches near the bladder neck, which helps keep the bladder and urethra in place [20] . Men with BPH may try transurethral microwave therapy (TUMT) to treat their BPH and eliminate UI.TUMT is a minimally invasive procedure where heat is applied to a special catheter that is inserted into the urethra. Once the temperature reaches the appropriate level, the tissues within the prostate are destroyed. This relieves pressure around the urethra [15] . Another type of minimally invasive procedure available tomen with BPH is transurethral needle ablation (TUNA). This procedure is done by putting a radiofrequency needle into the urethra. The heat from the frequency of the radio waves kills prostate tissue, relieving pressure around the urethra [13] . Another surgery that men with UI related to BPH may chose is transurethral resection of the prostate (TURP). TURP involves inserting an endoscope and a cutting instrument into the urethra to remove portions of the prostate that may be narrowing the urethra. This is one of the most effective treatments for BPH. However, TURP is a more invasive surgery and may not be the best option for everyone due to unintended side effects such as unwanted leaking and impotence [33] .

Case Study: Foley Catheter Due to Urinary Incontinence

The following presents a case study of a male client, Mr. C., who has a Foley catheter in place. A Foley catheter, also known as an indwelling catheter, is a tube that drains urine from the bladder, which can help treat urinary incontinence. It is easily inserted into the bladder through the urethra [6] . A small balloon is inflated with a sterile liquid to prevent the patient from pulling it out. Timing with catheters is critical because the longer a Foley catheter is in place, the greater the chance of the patient developing a urinary tract infection (UTI). A urinary tract infection is usually caused by a bacterium that gets pushed into the bladder, a sterile environment [5] .

Mr. C is a 72-year-old male who has an admitting diagnosis of a change in mental status. He has history of benign prostatic hyperplasia (BPH), an enlarged prostate. According to the Urinary Care Foundation (2017), “as the prostate enlarges, it can then squeeze down on the urethra [38] . The bladder's wall becomes thicker.”This means that the bladder wall is likely to weaken, leading to the inability to completely empty the bladder, a common symptom of urinary incontinence. A Foley catheter was chosen as the best option for Mr. C due to urinary retention most likely caused by his history with BPH. Mr. C's history also includes recurrent UTIs, chronic kidney disease related to diabetic neuropathy, and hypertension nephrosclerosis.

A urinalysis of Mr. C's urine was performed, which was yellow in color and cloudy in clarity. The urinalysis also gave crucial insight to Mr. C's lab values and their association with the possibility that Mr. C had developed a UTI. The two elevated lab values that were highlighted in Mr. C's urinalysis were the leukocyte and nitrite levels. Leukocyte esterase is produced by neutrophils in the body and is a normal response to pyuria, pus in the urine from an infection. Another indication of a possible infection is the elevated nitrite levels, which are not normally found in the urine. Urologists determine the presence of bacteria in the urine due to the fact that bacteria reduce urinary nitrates to nitrites [30] . The relevance of Mr. C's possible UTI adds another factor that could be a reason he's experiencing urinary retention.

Mr. C has a complex case when it comes to his urinary incontinence. His Foley catheter was supposed to help his UI, but instead it may have caused complication. It cannot be determined if Mr. C already had a UTI because tests were not performed prior to the insertion of his catheter. If Mr. C already had the UTI, it is possible that catheterization was a contributing factor to his urinary incontinence and possibly his confusion [30 , 3] . Mr. C's health care provide rstreated his UTI first by prescribing antibiotics [30] . He was also prescribed a combination drug therapy of alpha blockers and 5-alpha reductase inhibitorsas described above due to his history of BPH for the purpose of treating his UI [26] . Following a negative urinalysis, Mr. C. was taught Kegel exercises to strengthen his pelvic muscles. Within three months, Mr. C was able to control his urination and return to his activities of daily living.

Conflicts of Interest: The authors confirm that there is no conflict of interest regarding this manuscript.

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URINARY INCONTINENCE

Dec 08, 2011

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Slide 3. TOPICS COVERED. Prevalence and Impact of Incontinence Normal MicturitionAge-related Changes, Risk Factors, and Medical Conditions Associated with UITypes of Urinary IncontinenceAssessment: History, Physical Exam, TestingManagement StrategiesCatheters and Catheter Care. Slide 24. COMPONENTS OF COMPREHENSIVE ASSESSMENT OF UI.

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1. URINARY INCONTINENCE Suggestions for Lecturer -1�-hour lecture -Use GRS slides alone or to supplement own your teaching materials. -Refer to GRS for further content. -Refer to Geriatrics At Your Fingertips for updated information on patient evaluation and management. -Supplement lecture with handouts, eg, a sample bladder diary. -See GRS7 questions 48, 56, 61, 113, 179, 205, 239, and 286 for additional case vignettes on urinary incontinence. Suggestions for Lecturer -1�-hour lecture -Use GRS slides alone or to supplement own your teaching materials. -Refer to GRS for further content. -Refer to Geriatrics At Your Fingertips for updated information on patient evaluation and management. -Supplement lecture with handouts, eg, a sample bladder diary. -See GRS7 questions 48, 56, 61, 113, 179, 205, 239, and 286 for additional case vignettes on urinary incontinence.

2. Slide 3 TOPICS COVERED Prevalence and Impact of Incontinence Normal Micturition Age-related Changes, Risk Factors, and Medical Conditions Associated with UI Types of Urinary Incontinence Assessment: History, Physical Exam, Testing Management Strategies Catheters and Catheter Care

3. Slide 24 COMPONENTS OF COMPREHENSIVE ASSESSMENT OF UI History: including quality of life Physical examination: include cardiovascular, abdominal, musculoskeletal, neurologic, & genitourinary exams Testing: bladder diary, stress test, urinalysis, renal function Optional: PVR, urodynamics, cytology, other lab tests

4. Slide 25 ASSESSMENT: HISTORY Initiate discussion (50% do not report UI) Ask about specific symptoms: urgency (eg, with running water), frequency, nocturia, slow stream, terminal dribbling Determine UI characteristics: type (with urgency, stress maneuvers, insensate), onset, frequency, volume, timing, precipitants Identify associated factors: bowel & sexual function, medical conditions, medications Ask about quality of life: patient�s, caregiver�s

5. Slide 27 ASSESSMENT: PHYSICAL (2 of 4) Musculoskeletal: mobility, manual dexterity Neurologic: cervical disease suggested by limited lateral rotation & lateral flexion, interossei wasting, Hoffmann's or Babinski�s sign; lower extremity motor or sensory deficits Genitourinary: Men: prostate consistency, masses (cannot tell size by DRE); if uncircumcised, check for phimosis, paraphimosis, balanitis Women: vaginal mucosa for atrophy, pelvic support, prolapse Sacral reflexes Anal wink Bulbocavernosus reflex

6. Slide 38 BLADDER TRAINING FOR COGNITIVELY INTACT PATIENTS Urgency suppression Be still, don�t run to the bathroom Do pelvic muscle contractions When urgency decreases, then go to the bathroom Scheduled voiding while awake Initial toileting frequency: About 2 hrs, or use the shortest interval between voids from bladder diary if possible After 2 days without leakage: ? time between scheduled voids by 30�60 min, until can go 4 hours without leakage Success may take several weeks; reassure patient about any initial failures

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