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Journal of Wound, Ostomy & Continence Nursing:
doi: 10.1097/WON.0b013e318223162a
Continence Care Literature Review

Continence Literature Review 2010

Fellows, Jane MSN, RN, CWOCN; CONTRIBUTOR

Section Editor(s): Gray, Mikel L. PhD, FNP, PNP, CUNP, CCCN, FAANP, FAAN;

Free Access
Back to Top | Article Outline

General Concepts in Continence Care

C1. Metabolic Syndrome and Urologic Diseases

Gorbachinsky I, Akpinar H, Assimos DG. Reviews in Urology. 2010;12(4):e157–e180.

Article Type: Integrative review

Description/Results:

* Metabolic syndrome is an increasingly prevalent condition characterized by central adiposity, insulin resistance, dyslipidemia, endothelial dysfunction, low-grade inflammation, and low testosterone levels in men. Estimates of its prevalence among adults in the United States vary from 35% to 39%; the risk is highest among very obese individuals with BMI ≥50.

* Metabolic syndrome affects the genitourinary system in women and men; it is associated with an increased likelihood of benign prostatic hyperplasia and lower urinary tract symptoms in men including weak or interrupted urinary stream, nocturia, and incomplete bladder emptying. In women, it raises the risk for stress and urge incontinence. This risk is greatest in women with higher BMI, type 2 diabetes mellitus, and hypertension.

* Metabolic syndrome is associated with a variety of other urinary system disorders such as erectile dysfunction, infertility and prostate cancer in men, and urinary stones in both genders.

What does this mean for me and my practice?

Metabolic syndrome is strongly associated with lower urinary tract symptoms in both women and men. It raises the risk for stress and urge incontinence in women and the risk of urinary retention with prostatic enlargement in men. Existing evidence strongly suggests that increasing physical activity levels, when combined with weight loss, prevents or alleviates the severity of these conditions. WOC nurses should assess their patients for a history of metabolic syndrome and provide basic information about the condition and its association with incontinence or retention. Men may also be counseled about its negative impact on sexual function. Preventive efforts should focus on weight loss and increasing physical activity.

C2. Vitamin D and Pelvic Floor Disorders in Women: Results From the National Health and Nutrition Examination Survey

Badalian SS, Rosenbaum PF. Obstetrics & Gynecology. 2010; 115(4):795–803

Article Type: Research study

Description/Results:

* The authors report results of a cross-sectional analysis comparing vitamin D deficiency (defined as < 30 ng/mL) and the prevalence of urinary incontinence and pelvic floor disorders. Eighteen hundred eighty-one women participated in the study; the prevalence of vitamin D deficiency using the criterion established by the authors was very high at 80.1% in women aged 20 years and above and 85% in women aged 50 years and above. The prevalence of any pelvic floor disorder was 23%. The prevalence of urinary and fecal incontinence was 25.7% and 14.5% among women aged 50 years and over with vitamin D deficiency. Vitamin D deficiency was associated with an increased likelihood of urinary incontinence in women older than 50 years of age (odds ratio, 0.55, 95% CI: 0.34–0.91). Women with vitamin D deficiency were not found to be at greater risk for fecal incontinence.

What does this mean for me and my practice?

These results of this study demonstrate an association between vitamin D levels and pelvic floor disorders. However, it does not determine the nature of this relationship. At this point, there is insufficient evidence to recommend vitamin D supplementation for women with urinary or fecal incontinence.

C3. Tonsillectomy Does Not Improve Bed-wetting: Results of a Prospective Controlled Trial

Kalorin CM, Mouzakes J, Gavin JP, Davis TD, Feustel P, Kogan BA. Journal of Urology. 2010;184(6):2527–2531.

Article Type: Research study

Description/Results:

* Three hundred twenty children aged 3 to 15 years old were evaluated to determine the effect of tonsillectomy on nocturnal enuresis. All of the children had completed toilet training prior to enrollment in the study. Two hundred fifty underwent tonsillectomy and 69 acted as controls. Researchers graded the severity of hypertrophy of the tonsils on a scale of 1 to 4. Parents reported enuresis and urine elimination behaviors via a questionnaire completed before surgery and at 3 and 6 months following tonsillectomy for intervention patients and 3 and 6 months after enrollment for control subjects.

* The reported prevalence of nocturnal enuresis and daytime incontinence were comparable in the intervention and control groups at baseline. When followed up, the resolution rates for nocturnal enuresis at 3 and 6 months were 40% and 50% in children who underwent tonsillectomy group as compared to 35% and 48% in the control group (P = NS). No difference were seen when daytime urinary incontinence rates were compared at 3 and 6 months.

What does this mean for me and my practice?

Sleep apnea has been associated with increased nocturnal urine production, which is, in turn, associated with an increased risk for nocturnal enuresis for children and increased frequency of nocturia in adults. Hypertrophy of the tonsils is associated with snoring and has been hypothesized to predispose children to increased urine production at night and nocturnal enuresis. While these associations seem logical, the results of this study suggest that tonsillectomy does not influence the remission rates for enuresis and WOC nurses should not recommend tonsillectomy as a possible intervention for children with nocturnal enuresis or daytime urge incontinence.

C4. Quality of Life in Adults With Bladder Exstrophy-Epispadias Complex

Wittmeyer V, Aubry E, Liard-Zmuda A, et al. Journal of Urology. 2010;184(6):2389–2394.

Article Type: Research study

Description/Results:

* Although rare, the exstrophy-epispadias complex is a devastating congenital anomaly affecting the lower urinary tract, genitalia, and pelvic bone. A good deal has been written about evaluation and management of the exstrophy-epispadias complex in infants, children, and adolescents, but little is known about its long-term consequences. The authors of this article report on health-related quality of life in 25 persons with classic exstrophy-epispadias complex born between 1957 and 1990.

* Fifteen were originally managed by staged surgical reconstruction of their exstrophy, and 10 were managed by some form of urinary diversion. Respondents reported lower quality-of-life scores on social functioning (P = 0.004), vitality (P = 0.003), and mental health (P = 0.004) when compared to normative population, adults who experienced less incontinence had significantly higher quality of life than did persons with more frequent or severe incontinence. Adults who maintained spontaneous voiding reported higher physical functioning scores when compared to those who require intermittent catheterization to empty the bladder.

* Despite these limitations, 75% of the men and 66% of the women reported that they were sexually active, and 68% reported regularly participating in sports activities.

What does this mean for me and my practice?

Adults born with exstrophy-epispadias complex must cope with the sequelae of an extensive and disfiguring urinary system anomaly that requires multiple surgeries. Originally managed in pediatric settings alone, these individuals are growing into adulthood and are likely to encounter WOC nurses as they seek management of their urinary incontinence or urinary diversions. These findings of this study strongly suggest that aggressive attempts to promote continence and preserve spontaneous urethral voiding promote an optimal quality of life as these individuals move through adulthood.

C5. Prevalence of Double Incontinence, Risks and Influence on Quality of Life in a General Female Population

Slieker-ten Hove MC, Pool-Goudzwaard AL, Eijkemans MJ, Steegers-Theunissen RP, Burger CW, Vierhout ME. Neurourology and Urodynamics. 2010;29(4):545–550.

Article Type: Research study

Description/Results:

* The authors report a cross-sectional study of 1869 community-dwelling women, aged 45 to 85 years, with double fecal and urinary incontinence.

* The prevalence of double incontinence, defined as urinary leakage plus leakage of solid or liquid stool, was 10.3%. Women with pure urge urinary incontinence had the greatest likelihood of fecal incontinence (odds ratio 4.3; 95% CI: 2.4–7.9%). Similarly, women with fecal incontinence had an increased likelihood of urge urinary incontinence (odds ratio, 5.8; 95% CI: 1.8–18.2).

What does this mean for me and my practice?

Women with urge incontinence are at particular risk for suffering from fecal incontinence and vice versa. Therefore women presenting for overactive bladder with urge incontinence should be asked about fecal incontinence and women presenting with fecal incontinence should be queried about urge urinary incontinence.

C6. Urinary and Fecal Incontinence and Quality of Life in African Americans

Malmstrom TK, Andresen EM, Wolinsky FD, Schootman M, Miller JP, Miller DK. Journal of the American Geriatric Society. 2010;58(10):1941–1945.

Type of Article: Research study

Description/Results:

* This cross-sectional survey reported responses of 853 community-dwelling African American adults aged 52–68 years. Respondents with even occasional loss of urine or stool were classified as incontinent. Health-related quality of life was measured using the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) and depression was measured using the 11-item Center for Epidemiologic Studies–Depression Scale (CES-D).

* The prevalence of urinary incontinence was 12.1% and the prevalence of fecal incontinence was 5.0%. Respondents reporting UI and FI reported significantly worse physical function, role function, bodily pain, general health perceptions, vitality, social functioning, role emotional, and mental health than continent individuals (all P values were < .001). African Americans with urinary or fecal incontinence were also more likely to have depression based on CES-D scores than continence participants (P < .001).

What does this mean for me and my practice?

The results of this study strongly suggest that African American adults with urinary or fecal incontinence have a significantly impaired quality of life and are at risk for depression when compared age-matched continent peers. These findings also reveal that even occasional episodes of incontinence impair quality of life and demand treatment before symptoms progress and incontinence becomes more frequent.

C7. A Controlled Trial of an Intervention to Improve Urinary and Fecal Incontinence and Constipation

Schnelle JF, Leung FW, Rao SS, et al. Journal of the American Geriatric Society. 2010;58(8):1504–1511.

Article Type: Research study

Description/Results:

* The authors report results of a randomized controlled trial of an intervention designed to alleviate incontinence and constipation in nursing home residents. Subjects randomly allocated to the intervention were offered toileting assistance, exercise, and choice of food and fluid snacks every 2 hours for 8 hours per day over 3 months.

* Subjects randomized to the intervention group significantly increased their frequency of urination and defecation in the toilet, diminished the frequency of urinary episodes (P = 0.049). However, the frequency of fecal incontinence episodes did not differ significantly.

What does this mean for me and my practice?

Offering nursing home residents assistance with toileting improved urinary incontinence and increased the frequency of voids and bowel movements in the toilet. While this simple toileting intervention did not cure urinary or fecal incontinence, WOC nurses should encourage toileting assistance to preserve toileting and dignity and to alleviate urinary incontinence.

C8. Regulatory Guidelines for Bladder Management in Long-term Care: Are You in Compliance With F-Tag 315?

Doughty D, Kisanga J. Journal of Wound, Ostomy and Continence Nursing. 2010;37(4):399–411.

Article Type: Integrative review

Description/Results:

* The authors provide pragmatic advice for implementing revised F-315 guidelines for managing residents with urinary incontinence and review indications and guidelines for management of indwelling urinary catheters.

* Barriers to providing continence care in the long-term care facility are reviewed and helpful advice for overcoming these barriers discussed.

What does this mean for me and my practice?

Every WOC nurse who consults with long-term care facilities will benefit from reviewing this comprehensive review.

C9. How Do People Make Continence Care Happen? An Analysis of Organizational Culture in Two Nursing Homes

Lyons SS. Gerontologist. 2010;50(3):327–339.

Article Type: Research study

* The authors report results of an ethnographic study focusing on continence care in two nursing homes. Data were collected over a period of 15 months using a variety of techniques including observation, interviews with residents and care providers, and archival records. The study setting was 2 nursing homes located in the midwestern United States.

* The researchers characterized one nursing home as an open system, and the other nursing home was deemed a closed system. The open system was described as regularly introducing new staff, programs, and new technologies. They practice a policy of inclusive admission that resulted in a varied and complex patient mix with comparatively rapid turnover. As a result, residents had a variety of urine elimination disorders that could not be addressed by toileting programs combined with absorptive product use alone. The second nursing home was characterized as a closed system with less rapid introduction of new programs and technologies, resulting in less frequent staff turnover. This nursing home practiced a selective admission policy resulting in less patient turnover and residents with more similar urine elimination issues that were more readily addressed by scheduled toileting and use of absorptive products. The authors use ethnographic techniques to describe each system in detail, and how it influenced both bowel and bladder management. Of note, the researchers conclude that neither organizational culture fully supported interdisciplinary team efforts to maximize bladder and bowel health and prevent or alleviate incontinence.

What does this mean for me and my practice?

Although detailed and somewhat technical at points, a careful review of this article is especially valuable for any WOC nurse who consults with one or more long-term care facilities because it provides an outsider's perspective on corporate cultural factors influence the delivery of continence care.

Back to Top | Article Outline

Urinary Incontinence

C10. Knowledge, Attitudes, and Perceptions of Advanced Practice Nurses Regarding Urinary Incontinence in Older Adult Women

Keilman LJ, Dunn KS. Research and Theory in Nursing Practice. 2010;24(4):260–279.

Article Type: Research study

Description/Results:

* The researchers examined knowledge, attitudes, and perceptions of advanced practice nurses (APN) about urinary incontinence in older adult women.

* Most APN respondents reported that urinary incontinence is not a normal part of aging, prevalent, clinically relevant and should be managed by APN. They tended to report a positive attitude toward treating urinary incontinence and 70.3% reported routinely asking older women about urinary incontinence during health assessments.

* Approximately half reported receiving education about urinary incontinence in their graduate program, and about half of those who received education indicated that their incontinence education was inadequate to enable them to independently diagnose and manage incontinence.

* The majority of APN respondents also reported that they do not feel confident independently evaluating or treating urinary incontinence.

What does this mean for me and my practice?

WOC nurses are not alone in feeling less than optimally prepared for or confident when evaluating and treating urinary incontinence. Role development and additional research is needed to assist both WOC nurses and AP/WOC nurses to diagnose and manage women with urinary incontinence. Recent efforts at the WOCN Society's National Conference to more clearly define the role for continence management in the acute care setting is an excellent start toward the worthwhile goal.

C11. Are Former Female Elite Athletes More likely to Experience Urinary Incontinence Later in Life Than Nonathletes?

Bø K, Sundgot-Borgen. Journal of Scandinavian Journal of Medicine & Science in Sports. 2010;20(1):100–104.

Article Type: Research study

Description/Results:

* The authors report a cross-sectional study comparing urinary incontinence prevalence in 331 former elite athletes and 640 controls subjects. While actively competing, 10.9% and 2.7% of the former elite athletes reported stress and urge incontinence, respectively.

* At the time of data collection, 36.5% of the former elite athletes and 36.9% of the controls reported stress urinary incontinence. Similarly, 9.1% of the former athletes and 9.4% of controls reported urge incontinence. Neither difference was statistically significant.

What does this mean for me and my practice?

The results of this study can be used to reassure women that while participation in vigorous athletic activity may produce transient urine loss because of the unusual intensity of physical exertion, it does not increase the risk for urinary incontinence later in life.

C12. Urinary Incontinence Resolved After Adequate Vitamin D Supplementation: A Report of Two Cases

Gau JT. Geriatric Society. 2010;58(12):2438–2439.

Article Type: Case study/series

Description/Results:

* Vitamin D deficiency is associated with a variety of conditions, including muscle weakness and an increased risk of falls in older adults.

* The authors report 2 cases of adults, one a 78-year-old woman and the other a 59-year-old woman treated with supplemental vitamin D for stress and urge incontinence symptoms. The author reports resolution of urinary incontinence in both cases after vitamin D2 50,000 IU three times monthly.

What does this mean for me and my practice?

Vitamin D supplementation has been advocated for preventing or treating a variety of conditions, ranging from prevention of coronary artery disease to treatment of the common cold. Clinical experience generally suggests that individuals experiencing a deficiency of one or more vitamins will benefit from supplementation, but administration rarely produces the intended benefit. In both cases, women were found to have low serum levels of vitamin D, which may have accounted for the resolution of urinary incontinence symptoms. While these 2 case reports demonstrate the feasibility of vitamin D supplementation for women with urinary incontinence and low serum vitamin D2 levels, it does not provide adequate evidence needed for WOC nurses to recommend vitamin D supplementation for treating stress or urge incontinence.

C13. Long-term Efficacy of Pelvic Floor Muscle Rehabilitation for Older Women With Urinary Incontinence

Simard C, Tule MJ. Journal of Obstetrics Gynecology (Canada). 2010;32(12):1163–1166.

Article Type: Research study

Description/Results:

* The short-term efficacy of pelvic floor muscle training for treating stress, urge, and mixed urinary incontinence is well known, but little evidence exists documenting its long-term efficacy.

* The authors retrospectively reviewed medical records of 40 women (mean age 70 years) who underwent pelvic floor muscle training. At 5 years, 27.5% had improved, 57.5% remained stable, and 15% had deteriorated when compared with their status immediately following training. Twenty-nine patients (72.5%) were continuing their PFM exercises, and 42.5% were performing the exercises daily. All patients who persisted in their exercise program were improved or the same after five years as compared to 45.5% of patients who had not continued their exercises (P < 0.05).

What does this mean for me and my practice?

Among women who initially responded to treatment, the benefits of pelvic floor muscle training persisted for 5 years in 85%. Adherence to a maintenance program significantly improved the likelihood of maintaining or improving continence status when compared to women who discontinued their exercise regimen at the end of treatment. While other studies have documented the benefit of pelvic floor muscle training for 3–5 years, this study is unique because it provides evidence that long-term adherence to an exercise regimen provides a clinically relevant benefit.

C14. Performance Improvement in Practice: Managing Urinary Incontinence in Home Health Patients With the Use of an Evidence-Based Guideline

Egnatios D, Dupree L, Williams C. Home Health Nurse. 2010;28(10):620–628.

Article Type: Quality improvement report

Description/Results:

* The authors describe development of an evidence-based guideline for managing urinary incontinence without a catheter in the home health care setting. The Outcome and Assessment Information Set (OASIS) was used to document implementation of the guideline and results. Documentation occurred with admission to home care services, during resumption of care following a hospital admission, or during recertification after a 60-day episode.

* Development of the document coincided with staff education about urinary incontinence and its management. Mandatory educational sessions involved home health care nurses and physical and occupational therapists.

* Urinary incontinence scores rose 36% within 6 months and 55% within 9 months of implementation. The authors also discuss six lessons learned during implementation of the project.

What does this mean for me and my practice?

WOC nurses practicing in home health would benefit from reviewing the process used by these authors to improve urinary incontinence management in the home. A careful review of the lessons learned is particularly valuable before implementing a similar quality improvement project in your agency.

C15. The Hordaland Women's Cohort: Prevalence, Incidence and Remission of Urinary Incontinence in Middle-Aged Women

Jahanlu D, Hunskaar S. International Urogynecology Journal. 2010;21:1223–1229.

Article Type: Research study

Description/Results:

* The authors describe findings from a randomly selected, population-based group of 2,229 women in order to describe prevalence, incidence, and remission rates for urinary incontinence. Women were aged 41–45 years when enrolled in the study, and they were followed over a 10-year period; data are based on responses to 6 postal questionnaires administered throughout the observation period. The response rates to the surveys varied from 87% to 95.7%.

* The prevalence of urinary incontinence steadily rose until it peaked at age 51 years, followed by a period of diminished incidence of urinary incontinence and a diminished remission rate. The majority of urinary incontinence was characterized by respondents as mild; it varied from 63.5% to 57.8% of reported cases. In contrast, 28.9% to 33.8% characterized their incontinence severity as moderate and between 3.2% and 10.8% ranked their urinary leakage as severe to very severe. Incidence rates varied from 3.6% to 4.7%, but remission rates were substantially higher at 27.7% to as high as 44.4%.

* Stress and incontinence symptoms were most common and accounted for 33.7% to 46.7% of all women reporting urinary leakage; mixed incontinence symptoms were also frequent and accounted for 32.6% to 49.4%. Predominantly urge incontinence symptoms were reported by 9.6% to 14.3%. Other forms of urinary incontinence, including overflow symptoms, were typically reported by less than 10%.

What does this mean for me and my practice?

This article confirms previous epidemiologic studies about urinary incontinence in middle-aged women, and it adds new knowledge that should influence WOC nursing practice. It confirms the comparatively high prevalence of urinary incontinence in middle-aged women, reminding us of the importance of routine screening of these women, combined with counseling about bladder health and the importance of early intervention when incontinence persists. It also confirms previous studies that demonstrate that stress or mixed stress and urge incontinence symptoms predominate. In contrast, the relatively high remission rate has been documented in men but not in women. This finding provides encouraging news that urinary incontinence may improve or resolve, and provides further incentive to pursue conservative management techniques before resorting to surgery or more invasive techniques for treating urinary leakage.

C16. Daily-Living Management of Urinary Incontinence: A Synthesis of the Literature

John WS, Wallis M, Griffiths S, McKenzie S. Journal of Wound, Ostomy and Continence Nursing. 2010;37(1):80–90.

Article Type: Integrative review

Description/Methods:

* The authors review literature focusing on self-management strategies for community-dwelling women and men.

* The authors describe a variety of containing, concealing, and modifying strategies used to manage urinary incontinence. The authors review strategies viewed as useful and effective, as well as those that may paradoxically impair health or exacerbate urinary incontinence.

What does this mean for me and my practice?

WOC nurses should read this comprehensive review in order to increase their awareness of common strategies used to manage incontinence. Individual counseling with patients should encourage safe and effective strategies while discouraging use of strategies that are ineffective or potentially harmful.

C17. Mirabegron, a β3-Adrenoceptor Agonist for the Potential Treatment of Urinary Frequency, Urinary Incontinence or Urgency Associated With Overactive Bladder

Tyagi P, Tyagi V. Drugs. 2010;13(10):713–722.

Article Type: Integrative review

Description/Results:

* Acting under the influence of higher centers in the brain and brainstem, the sympathetic nervous system prevents premature micturition via release of the neurotransmitter norepinephrine in the detrusor muscle. Norepinephrine attaches to β-3 receptors in the bladder wall to relax the detrusor muscle until an opportunity for voiding occurs and the decision to urinate is made.

* Mirabegron (YM-178) is a β-3 receptor agonist that is undergoing Phase III clinical trials to determine if it is safe and effective for treatment of overactive bladder. The drug promotes detrusor muscle relaxation by enhancing the activity of norepinephrine on β-3 receptors in the bladder wall.

What does this mean for me and my practice?

All of the drugs currently approved for treatment for overactive bladder belong to the drug class known as antimuscarinics. These drugs act by blocking the actions of the neurotransmitter acetylcholine at M2 and M3 muscarinic receptors in the bladder wall. WOC nurses should closely monitor progress of these clinical trials since approval of Mirabegron will provide another class of drug for treatment of overactive bladder and urge urinary incontinence.

C18. Percutaneous Tibial Nerve Stimulation Effects on Detrusor Overactivity Incontinence Are Not due to a Placebo Effect: A Randomized, Double-Blind, Placebo Controlled Trial

Finazzi-Agrò E, Petta F, Sciobica F, Pasqualetti P, Musco S, Bove P. Journal of Urology. 2010;184(5):2001–2006.

Article Type: Research study

Description/Results:

* In a randomized controlled trial, 35 women with detrusor overactivity who proved refractory to antimuscarinic therapy were randomly allocated to treatment with percutaneous tibial nerve stimulation (n = 18) or a sham treatment consisting of a similar percutaneous needle placed in the gastrocnemius muscle (n = 17). Both groups underwent 12-week, 30-minute treatment sessions. Three subjects, 1 in the active treatment group and 2 in the placebo group, did not complete the 12 sessions.

* Patients randomized to the active treatment achieved greater improvement in the number of incontinence episodes, number of voids, voided volume, and incontinence quality of life score than subjects randomly allocated to the control group (all P values < 0.001). Twelve of 17 subjects (71%) who received percutaneous tibial nerve stimulation were deemed responders as compared tonone (0%) of patients in the control group.

What does this mean for me and my practice?

Percutaneous tibial nerve stimulation is a viable option for treatment of patients who are nonresponsive to oral antimuscarinic therapy. Treatment requires placement of a single percutaneous needle in the posterior tibial nerve near the ankle for a total of 12, 30-minute weekly stimulation sessions. Treatments are typically delivered by WOC or continence nurses.

C19. Randomized, Placebo Controlled Study of Electrical Stimulation With Pelvic Floor Muscle Training for Severe Urinary Incontinence After Radical Prostatectomy

Yamanishi T, Mizuno T, Watanabe M, Honda M, Yoshida K. Journal of Urology. 2010;184(5): 2007–2012.

Article Type: Research study

Description/Results:

* Transient urinary incontinence is extremely prevalent following radical prostatectomy and mild long-term urinary leakage is common. The efficacy of pelvic floor muscle training, with or without transrectal electrical simulation, remains controversial.

* The 56 men who participated in this study were randomly allocated to pelvic floor muscle exercises plus active transrectal electrical stimulation (intervention group) or pelvic floor muscle exercises plus use of a sham transrectal probe (control group). All participants were classified as having severe postprostatectomy incontinence; defined as >200 Gm daily based on pad testing.

* A greater number of men who were randomized to exercises plus active stimulation achieved continence at 1, 3, and 6 months, respectively (P = 0.0161, P = 0.0021, and P = 0.0156). The time to achieve continence was significantly shorter in the active treatment group versus the control/sham group (2.71 ± 2.6 vs. 6.82 ± 3.9 months, P = 0.0006). Men in the active treatment group had significantly better scores when asked to rank the severity of their urinary leakage at 1 month, but no differences were observed at 12 months.

What does this mean for me and my practice?

The results of this study suggest that transrectal simulation plus pelvic floor muscle exercises results in an earlier return to continence when compared to pelvic floor muscle training alone. Nevertheless, results also demonstrate that long-term results (measured at 12 months posttreatment) reveal that both treatments are equally successful in relieving postprostatectomy incontinence. WOC nurses who have access to electrical stimulation may choose to add this modality to a pelvic floor muscle training program for men with urinary incontinence following radical prostatectomy. Nevertheless, pelvic floor muscle exercises remain a primary WOC nurse intervention for the man with post prostatectomy urinary incontinence.

C20. Combined Behavioral and Individualized Drug Therapy Versus Individualized Drug Therapy Alone for Urge Urinary Incontinence in Women

Burgio KL, Goode PS, Richter HE, Markland AD, Johnson TM II, Redden DT. Journal of Urology. 2010;184(2):598–603.

Article Type: Research study

Description/Results:

* The authors report results of a randomized controlled trial comparing drug therapy with and without behavioral interventions.

* Sixty-four community-dwelling women were randomly allocated to 8 weeks (4 visits) of drug therapy alone (n = 32) or drug therapy plus behavioral training (n = 32). Drug therapy was individually titrated and side effects were proactively managed. Behavioral training included pelvic floor muscle training and urge suppression techniques.

* Both groups experienced improvement in their continence status. An intent-to-treat analysis revealed no difference when women randomized to drug therapy plus behavioral interventions were compared to women on drug therapy alone (88.5% vs. 78.3%, P = 0.16). No differences were detected when a complete analysis was undertaken (91.5% for drug therapy alone vs. 86.2%, P = 0.34).

What does this mean for me and my practice?

Results of this trial suggest that women managed with drug therapy alone benefit as much from careful follow-up and proactive management of drug side effects as do women managed with drug therapy plus behavioral interventions. How this trial translates into “real world” practice, where patients receive far less frequent follow-up with clinicians, cannot be determined.

C21. Adherence to Behavioral Interventions for Urge Incontinence When Combined With Drug Therapy: Adherence Rates, Barriers, and Predictors

Borello-France D, Burgio KL, Goode PS, et al. Urinary Incontinence Treatment Network Physical Therapy. 2010;90(10):1493–1505.

Article Type: Research study

Description/Results:

* Barriers affecting adherence to behavioral interventions for urinary incontinence were examined in 307 women who participated in a randomized controlled trial comparing pharmacotherapy with and without behavioral interventions for management of overactive bladder with urge incontinence. Data were collected during the study and 1 year following treatment.

* During the supervised intervention, 81% of women exercised 5 to 6 days per week, 87% performed at least 30 pelvic floor muscle contractions on a daily basis, and >90% reported using the urge suppression strategy to successfully prevent an episode of incontinence. When queried at 1 year, 32% of respondents stated that they performed pelvic floor muscle exercises 5 to 6 days per week, and slightly more than half (56%) stated they performed 15 or more pelvic floor muscle contractions when they exercised. The most frequently reported barriers to adherence were: 1) difficulty remembering to exercise and 2) finding time to exercise.

What does this mean for me and my practice?

The proportion of women who adhered to behavioral training in this study differs significantly from that reported by Simard and Tule earlier in this review. We believe that this difference is most likely attributable to the increased demands of a tightly controlled clinical trial versus adherence to a clinical program described by Simard and Tule. Nevertheless, the researchers identify two important barriers to adherence to a behavioral intervention program, remembering to complete exercises and finding time to exercise. WOC nurses should carefully consider these insights and tailor a pelvic floor muscle exercise program that can be easily integrated into a woman's daily schedule and one that involves the minimum number of contractions likely to achieve or maintain continence.

C22. Contributors to Satisfaction With Combined Drug and Behavioral Therapy for Overactive Bladder in Subjects Dissatisfied With Prior Drug Treatment

Wyman JF, Harding G, Klutke C, et al. Journal of Wound, Ostomy and Continence Nursing. 2010;37(2):199–205.

Article Type: Research study

Description/Results:

* The authors report a descriptive study evaluating treatment satisfaction with a self-administered behavioral intervention, combined with pharmacotherapy in 15 persons who participated in an open label study of persons with overactive bladder who reported dissatisfaction with antimuscarinic therapy prior to enrollment in the study.

* The main reason for dissatisfaction prior to study enrollment was a perceived lack of efficacy. When asked about satisfaction with management that combined pharmacotherapy and behavioral interventions, participants' reasons given for satisfaction with combined treatment were improvement in OAB symptoms, attention of clinic staff, review of educational materials on OAB symptoms and treatment, and keeping a bladder diary.

What does this mean for me and my practice?

Similar to the results of Burgio's group, findings from this study suggest that patients benefit from a program that combines behavioral interventions with pharmacotherapy. Traditional principles of WOC intervention, including patient education, attention to the patient, and her or his complaints, improved satisfaction with management of overactive bladder symptoms. In addition, the study suggests that completion of a bladder diary provides a therapeutic as well as documentary role in the management of persons with urge incontinence.

C23. The Effect of Medication Use on Urinary Incontinence in Community-Dwelling Elderly Women

Ruby CM, Hanlon JT, Boudreau RM, et al; Health, Aging and Body Composition Study. Journal of the American Geriatric Society. 2010;58(9):1715–1720.

Article Type: Research study

Description/Results:

* This longitudinal cohort study followed 959 community-dwelling women with urinary incontinence. Participants were aged 65 years and older and enrolled in a larger trial that focused on health, aging, and body composition.

* The prevalence of urinary incontinence following 3 years of observation was 20.5%. The most common medications with potential side effects affecting continence were thiazide diuretics and systemic estrogens. Multivariable logistic regression analyses revealed taking an alpha-adrenergic blocking agent (used by 2.2% of participants) or systemic estrogen raised the risk for urinary incontinence when compared to nonusers. The adjusted odds ratio for women using alpha-adrenergic blockers was 4.98 (95% confidence interval: 1.96–12.64) and the adjusted odds ratio for women using estrogens was 1.60 (95% CI: 1.08–2.36). Taking an anticholinergic drug or central nervous system agent did not influence the likelihood of urinary incontinence.

What does this mean for me and my practice?

Changing medications may, in highly selected cases, prevent or alleviate urinary incontinence. Results of this study suggest that discontinuing an alpha-adrenergic antagonist such as doxazosin or hytrin or discontinuing systemic estrogenic agents may reduce UI in community-dwelling women. However, use of diuretic medications, taken by 24.3% of participants, did not influence the likelihood of urinary incontinence. Therefore, WOC nurses should work with the patient's physician or nurse practitioner to determine the effects of specific medications on continence.

C24. Post-prostatectomy Incontinence: Implications for Home Health Clinicians

Smith JE. Home Health Nurse. 2010 Oct;28(9):542–548.

Article Type: Integrative review

Description/Results:

* The author summarizes existing research and literature concerning postprostatectomy urinary incontinence and discusses implications for nurses practicing in a home health care setting.

* The article summarizes conservative, pharmacologic, and surgical options for managing postprostatectomy incontinence, including pelvic floor muscle exercises.

What does this mean for me and my practice?

Any WOC nurse who provides care for patients with postprostatectomy urinary incontinence will benefit from reviewing this comprehensive and accessible review article.

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Postpartum Urinary Incontinence

C25. Prevalence of Postpartum Urinary Incontinence: A Systematic Review

Thom DH, Rortveit G. Acta Obstetricia Gynecologica Scandinavica. 2010;89(12):1511–1522.

Article Type: Systematic review

Description/Results:

* The authors report a systematic review of prevalence studies of postpartum incontinence enrolling at least 100 women. Data from 33 studies, enrolling more than 23,400 women, were pooled to provide prevalence of postpartum urinary incontinence.

* During the first 3 months postpartum, the pooled prevalence of urinary incontinence was 33% (95% CI: 32–36%). The prevalence of women experiencing daily episodes of incontinence was 3% (95% CI: 3–4%). Women who delivered vaginally were twice as likely to report UI when compared to women undergoing caesarean section (31% vs 15%). Longitudinal studies showed little change in incontinence prevalence over the first year following delivery.

What does this mean for me and my practice?

The prevalence of postpartum incontinence is comparatively high at 33%, and 10% of these women will experience relatively severe incontinence resulting in daily urine loss. These data reinforce the need to teach all women, and especially those anticipating vaginal delivery, pelvic floor muscle exercises in order to prevent or alleviate urinary incontinence following pregnancy and delivery. WOC nurses interested in postpartum incontinence or women's health in particular should review this robust systematic literature review.

C26. Women's Explanations for Urinary Incontinence, Their Management Strategies, and Their Quality of Life During the Postpartum Period

Hermansen IL, O'Connell BO, Gaskin CJ. Journal of Wound, Ostomy and Continence Nursing. 2010;37(2):187–192.

Article Type: Research study

Description/Results:

* The authors report a cross-sectional study of 75 women who had given birth within 3 months of data collection. The questionnaire focused on perceived causes of urinary incontinence, type of incontinence, average volume of urine loss, and strategies used to manage urinary leakage. Women completed three validated instruments that measured symptom bother and health-related quality of life.

* The prevalence of urinary incontinence in this smaller study was 28%, which is comparable to the 33% pooled prevalence reported by Thom and Rortveit previously. Slightly more than half (55%) complained primarily of urine loss with physical activity (indicating stress urinary incontinence), half of the women stated that they were moderately to greatly bothered by their urinary incontinence and lower urinary tract symptoms. The most common strategies used to manage incontinence were more frequent toileting and use of absorptive products.

What does this mean for me and my practice?

The findings of this study broadly concur with the results reported by Thom and Rortveit that postpartum urinary incontinence is prevalent and clinically relevant. Strategies used to manage incontinence included more frequent toileting and use of absorptive products. However, although 76% reported that they attributed their urine loss to weakened pelvic floor muscles, only 25% reported performing pelvic floor muscle exercises. This observation alone defines an opportunity for both individual and public education by a qualified WOC nurse.

C27. Urinary Incontinence and Weight Change During Pregnancy and Postpartum: A Cohort Study

Wesnes SL, Hunskaar S, Bo K, Rortveit G. American Journal of Epidemiology. 2010;172(9):1034–1044.

Article Type: Research study

Description/Results:

* Both obesity and pregnancy are associated with an increased likelihood of urinary incontinence but evidence concerning the impact of weight gain during pregnancy on incontinence is not clear.

* Researchers gathered data on 12,679 primiparous women who were continent prior to pregnancy; women were queried about their weight gain and continence status at weeks 15 and 30 of pregnancy and 6 months postpartum.

* Women who experienced a weight gain greater than the 50th percentile during weeks 0–15 of pregnancy had a slightly higher incidence of UI at week 30 of pregnancy when compared with those who whose weight gain was ≤ the 50th percentile. A weight gain of more than the 50th percentile during pregnancy was not associated with an increased prevalence of UI when queried at 6 months postpartum.

* For each kilogram of weight they lost from delivery to 6 months postpartum, women who reported urinary incontinence during pregnancy experienced a 2.1% increase in the likelihood of regaining continence (relative risk = 0.98, 95% confidence interval: 0.97 to 0.99).

What does this mean for me and my practice?

Despite expectations, women who gained more weight during their pregnancy were not at greater risk for urinary incontinence than were women who experienced smaller weight gains. However, weight loss following delivery is important because it lowers the risk for urinary incontinence at 6 months postpartum and the subsequent risk for long-term incontinence.

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Neurogenic Bladder

C28. Management Goals for the Spina Bifida Neurogenic Bladder: A Review From Infancy to Adulthood

Mourtzinos A, Stoffel JT. Urologic Clinics of North America. 2010;37(4):527–535.

Article Type: Integrative review

Description/Results:

* The authors review spina bifida defects and their impact on lower urinary tract function. Emphasis is placed on urologic goals of management including preservation of renal function, promotion of urinary continence, and genitourinary issues associated with late adolescence and the transition to early adulthood.

* Common challenges associated with the management of children and adolescents with spina bifida are reviewed, including persistent urinary incontinence recurring urinary tract infections. Recommendations for ongoing long-term monitoring for renal function and urinary system malignancy are especially useful.

What does this mean for me and my practice?

This article is valuable to any WOC nurse whose practice includes management of children with myelodysplasia. Information about urinary and sexual function during late adolescence and the early adulthood transition are especially useful as this population ages and struggles to establish independence as they grow from children to adults and their parents, who typically act as primary care providers, age.

C29. Pelvic Floor Muscle Training in the Treatment of Lower Urinary Tract Dysfunction in Women With Multiple Sclerosis

Lúcio AC, Campos RM, Perissinotto MC, Miyaoka R, Damasceno BP, D'ancona CA. Neurourology & Urodynamics. 2010;29(8):1410–1413.

Article Type: Research study

Description/Results:

* The authors describe a small randomized controlled trial enrolling 27 women with multiple sclerosis and lower urinary tract symptoms including urinary incontinence. Women with significant functional limitations were excluded from participation, as were women experiencing an acute exacerbation of multiple sclerosis symptoms. The active intervention comprised a pelvic floor muscle training program using rehabilitation techniques where patients are asked to perform 30 contractions three times daily. Biofeedback was provided using intravaginal manometry. Control patients underwent insertion of the vaginal manometer but were not instructed to contract the pelvic floor muscles during clinic sessions or any instructions about home training.

* Women randomized to the active intervention group experienced statistically significant and clinically relevant reductions in pad weights, number of pads used per day, and frequency of nocturia when compared to patients randomized to the control group.

What does this mean for me and my practice?

The findings of this study are important to WOC nursing practice because they demonstrate that pelvic floor muscle training can be effective in highly selected women with neurogenic bladder dysfunction associated with multiple sclerosis. Given the complexity of these patients, treatment may be delivered by an experienced continence nurse or a physical therapist.

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Defecation Disorders

C30. Posterior Tibial Nerve Stimulation for Fecal Incontinence

Findlay J, Maxwell-Armstrong C. British Journal of Nursing. 2010;19(12):750–754.

Article Type: Integrative review

Description/Results:

* The authors review 8 studies focusing on percutaneous posterior tibial nerve stimulation (PTNS) for treatment of fecal incontinence. These studies were conducted in Europe between 2003 and 2010 and the number subjects in each study ranged from 2 to 32.

* The study design and inclusion criteria varied sufficiently to limit the conclusions that could be drawn from this review, but PTNS seemed to have some efficiacy in controlling fecal incontinence.

* Since this technique is non-invasive, it may be of value particularly in those persons whose comorbidities make them poor surgical canduidates.

What does this mean for me and my practice?

This article provides an overview of fecal incontinence and the current options available for treatment. A larger randomized control trial of PTNS would be a welcome addition to the evidence base for management of fecal incontinence.

C31. Review of the Efficacy and Safety of Transanal Irrigation for Neurogenic Bowel Dysfunction

Emmanuel A. Spinal Cord. 2010;48(9):664–673.

Article Type: Integrative review

Description/Results:

* Two systems for transanal irrigation of the bowel have been developed. Alternatively, the technique may be accomplished using a stoma irrigation system with a cone shaped tip. This integrative review focuses on the efficacy and safety of transanal irrigation in patients with paralyzing spinal disorders such as spina bifida or spinal cord injury. Twenty-three studies evaluating the efficacy and safety of transanal irrigation using a variety of techniques are described.

* Limited evidence suggests that transanal irrigation is safe and effective for managing neurogenic bowel in patients with spinal cord injury, spina bifida, and cauda equina syndrome. Results of 1 study discussed in this review suggest that transanal irrigation is more effective than conservative bowel management in managing constipation, preventing incontinent episodes, and improving quality of life. The authors go on to state that existing evidence reveals that the greatest promise is found in children with spina bifida.

What does this mean for me and my practice?

Transanal irrigation using a commercially available system is a viable alternative for managing neurogenic bowel in patients with spina bifida, cauda equina syndrome, or spinal cord injury. Additional research is needed before more definitive statements about its comparative effectiveness and impact on fecal incontinence episodes can be made.

C32. Prevalence of Fecal Incontinence in Adults Aged 30 Years or More in General Population

Aitola P, Lehto K, Fonsell R, Huhtala H. Colorectal Disease. 2010;12(7):687–691.

Article Type: Research study

Description/Results:

* The authors measured prevalence of fecal incontinence in a population-based, random sample of 8,000 Finnish adults aged 30–81 years. Results are based on cross-sectional data from a survey that incorporated several validated instruments and queried demographic and related factors.

* The prevalence of fecal incontinence in this population was 10.6% (95% CI: 9.5–11.6%); women were affected more often than men (11.9% vs 8.7%). Moderate to severe fecal incontinence, resulting in leakage twice a month of more often, was reported by 5.2% (95% CI: 4.5%-6%). A comparatively small portion had sought advice from a health care provider (27.2%) and only 12.4% reported that they had been asked about fecal incontinence when receiving health care services. Ten percent stated they had received treatment for fecal incontinence but 66% of patents reporting moderate to severe symptoms felt they needed treatment.

What does this mean for me and my practice?

The prevalence rate reported in this article is comparatively high, but it includes any report of fecal incontinence, however, mild. Nevertheless, the prevalence of moderate to severe fecal incontinence was significant at 5.2%. Of equal importance is the observation that 12.4% had asked their health care provider about their incontinence and 10% received treatment. These findings serve as a strong reminder that the WOC nurse must raise the subject of fecal incontinence with patients, using language they can understand and relate to, and assist patients to obtain appropriate care.

C33. The Effects of Conservative Treatment for Constipation on Symptom Severity and Quality of Life in Community-Dwelling Adults

Ostaszkiewicz J, Hornby L, Millar L, Ockerby C. Journal of Wound, Ostomy and Continence Nursing. 2010;37(2):193–198.

Article Type: Research study

Description/Results:

* The authors describe use of a conservative, tailored intervention for management of constipation. Components of the intervention included daily recreational exercise (walking for 20 minutes), fluid intake, dietary advice, education about responding to the gastrocolic reflex, positioning for optimal defecation, and use of over-the-counter laxatives.

* Twenty-seven community-dwelling women (mean age 64 years) with constipation and lower urinary tract symptoms were evaluated and given an individually tailored program. The intervention significantly reduced the severity of overall constipation symptoms (P < 0.01), and improved health-related quality of life (P < 0.01). Patients also achieved statistically significant improvements in psychosocial discomfort, worries, and concerns.

What does this mean for me and my practice?

Although efficacy cannot be concluded from this single group trial, the results of this study suggest that an individually tailored, conservative program that addresses fluid and dietary issues, exercise, positioning during defecation, response to the gastrocolic reflex, and use of over-the-counter laxatives relieves bothersome symptoms and improves quality of life in patients with chronic constipation.

C34. Health Literacy and Emotional Responses Related to Fecal Incontinence

Patel K, Bliss DZ, Savik K. Journal of Wound, Ostomy and Continence Nursing. 2010;37(1):73–79.

Article Type: Research study

Description/Results:

* The authors report a secondary analysis of data focusing on the terms 89 community-dwelling elders use when describing fecal incontinence. Data were obtained from content analysis of participants' statements reported in field notes taken by data collectors and their responses to data forms and questions; 73% of respondents were women and the mean age of the sample was 59 years.

* Participants used a variety of descriptive terms when referring to fecal incontinence including “loose stools,” “skid marks,” or “bowel spells.” Only one participant out of 89 used the term fecal incontinence.

What does this mean for me and my practice?

Querying patients about fecal incontinence is unlikely to determine the presence of involuntary stool loss in many patients. Instead, the WOC nurse should allow patients to use descriptive terms when describing fecal incontinence in an environment that both provides adequate privacy and ensures dignity and support enabling them to describe this obviously distressing condition.

C35. Fecal Incontinence and Depression: Cause or Effect?

Bailey N, Parés D. Colorectal Disease. 2010;12(5):397–398.

Article Type: Integrative review

Description/Results:

* The authors review research suggesting that fecal incontinence may be a risk or etiologic factor of fecal incontinence rather than a psychosocial sequela.

* Similar to urinary incontinence, the negative impact of fecal incontinence on health-related quality of life and sexual function is briefly discussed. However, the authors also point out that the natural history of altered levels of neurotransmitters acting in the central nervous system, especially serotonin, may act as an etiologic factor leading to fecal incontinence rather than a consequence of the condition. A systematic review and meta-analysis is discussed that summarizes evidence that tricyclic antidepressants may alleviate irritable bowel symptoms by altering available serotonin and acetyl choline activity in the bowel, influence transit time, stool consistency, and rectal urgency.

What does this mean for me and my practice?

Though provocative, there is insufficient evidence to conclude whether depression is an etiologic factor in the development of fecal incontinence or a psychosocial sequela. Nevertheless, the WOC nurse should remain alert to research in this area because it may reveal that aggressive identification of depression, and its early treatment, may prevent both urinary and fecal incontinence in some patients.

C36. Prevalence of Bowel Symptoms in Women With Pelvic Floor Disorders

Raza-Khan F, Cunkelman J, Lowenstein L, Shott S, Kenton K. International Urogynecology Journal and Pelvic Floor Dysfunction. 2010;21(8):933–938.

Article Type: Research study

Description/Results:

* The prevalence of fecal incontinence and bowel elimination symptoms were evaluated in a group of 463 women presenting to a urogynecologic clinic for evaluation and management of pelvic floor prolapse. Only 3% listed bowel elimination problems as part of their presenting complaint, but 83% reported bowel elimination symptoms or fecal incontinence when completing a validated instrument querying these conditions.

* The most prevalent bowel elimination symptom was incomplete emptying at the end of a bowel movement (56%). More than half of the women reported straining to have a bowel movement (55%) and inability to control flatus (54%). Nine percent reported fecal incontinence and 36% reported urinary incontinence.

What does this mean for me and my practice?

Similar to clinical experience with urinary incontinence, patients are reluctant to report bowel elimination symptoms or fecal incontinence when seeking care. Instead, they tend to present with other complaints and will report these symptoms only when prompted to by a caring clinician. The findings of this study also support Bliss and colleagues, who note that patients do not typically use the term fecal incontinence to describe involuntary loss of liquid or solid stool. In order to identify, diagnose, and manage bowel elimination symptoms in women, WOC nurses must ask patients about these conditions in an environment that preserves privacy and dignity.

C37. Rectal Trauma and Associated Hemorrhage With the Use of the ConvaTec Flexi-Seal Fecal Management System: Report of 3 Cases

Sparks D, Chase D, Heaton B, Coughlin L, Metha J. Diseases of Colon Rectum. 2010Mar;53(3):346–349.

Article Type: Case study/series

Description/Results:

* Cases of rectal trauma and severe acute bleeding are described in 3 seriously ill patients in one hospital where traumatic removal or prolonged duration of use of the fecal management system (FMS) occurred.

* With 2 of the patients' traumatic removal of the system occurred, and rectal lacerations were the cause of the bleeding. In the 3rd patient, the system had been in place for 21 days and endoscopy revealed a rectal ulcer that could have been caused by pressure. Two patients were receiving anticoagulation therapy with warfarin and one was receiving aspirin.

* While FMS is an effective way to manage diarrhea and it helps to prevent skin breakdown, serious consequences can occur and must be used with care in debilitated patients especially if they are on anticoagulation therapy.

What does this mean for me and my practice?

Policies concerning the use of the FMS may need to include a warning about careful avoidance of traumatic removal during transfers and repositioning. For those patients on anticoagulation therapy, it may be appropriate to remove or change the device more often than the manufacturer recommends.

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Incontinence-Associated Dermatitis

C38. Pressure Ulcers and Incontinence-Associated Dermatitis: Effectiveness of the Pressure Ulcer Classification Education Tool on Classification by Nurses

Beeckman D, Schoonhoven L, Fletcher J, et al. Quality and Safety in Health Care. 2010 Oct;19(5):e3.

Article Type: Research study

Description/Results:

* The authors describe results of a randomized controlled trial evaluating the efficacy of an educational intervention, the Pressure Ulcer Classification Education tool (PUCLAS) designed to teach nurses to more accurately differentiate partial thickness (Stage or Grade II) pressure ulcers from incontinence-associated dermatitis (IAD).

* 1217 Belgian, Dutch, English, and Portuguese nurses attending a wound care conference were randomly allocated to the PUCLAS intervention or a control group. At baseline evaluation, 44.5% of photographs were classified correctly; testing after the intervention revealed a significantly higher accurate classification of photographs among the intervention group (63.2%) versus 53.1% accuracy among the control group (P < 0.001).

* These scores indicated that 70.7% of the intervention group correctly identified photographs of IAD as compared to 35.6% of the control group.

What does this mean for me and my practice?

The PUCLAS is effective for improving nurses' ability to differentiate lower stage pressure ulcers from IAD based on visual inspection alone. WOC nurses will benefit from incorporating this educational intervention into their routine education of nonspecialty practice nursing colleagues.

C39. The Incontinence-Associated Dermatitis and Its Severity Instrument: Development and Validation

Borchert K, Bliss DZ, Savik K, Radosevich DM. Journal of Wound, Ostomy and Continence Nursing. 2010;37(5):527–535.

Article Type: Research study

Description/Results:

* Two WOC nurses worked with experienced researchers to develop and validate the Incontinence Associated Dermatitis (IAD) Severity Instrument. The tool identifies 13 locations for IAD and provides a range of colors indicating varying degrees of inflammation. The instrument includes items for identification of associated rashes and severity of skin erosion and an example of full thickness skin loss over a bony prominence indicating a pressure ulcer.

* Initial testing revealed good content and criterion validity. The instrument demonstrated strong interrater reliability among WOC nurses and among nonspecialty nursing staff. The authors report that minimal instruction was required to teach nurses to use the IADS instrument.

What does this mean for me and my practice?

Differentiation of IAD and pressure ulcers is clinically relevant but difficult. Assessment relies on visual inspection, which is especially challenging for the nonspecialist nurse. Development of an instrument to aid nurses in accurately describing IAD, judging its severity, and differentiating the condition from a pressure ulcer is badly needed. Development of this instrument represents an important step toward achieving this ambitious goal.

C40. Optimal Management of Incontinence-Associated Dermatitis in the Elderly

Gray M. American Journal of Clinical Dermatology. 2010;11(3):201–210.

Article Type: Integrative review

Description/Results:

* The author discusses the physiology of the skin's moisture barrier and the pathophysiology of its compromise when exposed to urine and stool. Current research concerning the diagnosis, prevention, and treatment of IAD in the elderly patient is reviewed.

* Principles of a defined skin care regimen are discussed in detail, including principles for selecting an appropriate skin protectant.

What does this mean for me and my practice?

WOC management of IAD focuses on construction and regular implementation of a defined skin care regimen that removes irritants from the skin, followed by application of a skin protectant. A review of this article will be valuable for WOC nurses seeking to establish or update the skin care regimen for incontinent patients in their facility.

C41. Improving Diaper Design to Address Incontinence-Associated Dermatitis

Beguin AM, Malaquin-Pavan E, Guihaire C, et al. BMC Geriatrics. 2010;10:86.

Article Type: Research study

Description/Results:

* The authors describe efforts to improve the design of a wrap around absorbent brief designed to reduce the risk of IAD when used in the clinical setting. They placed an acidic, curled-type of cellulose between the top sheet in contact with the skin and the absorption core beneath containing a polyacrylate superabsorber in order to preserve the compromised acid mantle of the perineal skin in patients with urinary or fecal incontinence. The redesigned brief also incorporated an air-permeable side panels to minimize skin occlusion and swelling of the stratum corneum.

* The redesigned brief was found to have a surface pH of 4.6 that persisted after repeated wetting throughout a 5-hour period. Side panels made from nonwoven material with an air-permeability of more than 1200 l/m2/s were deemed to prevent excessive hydration of the stratum corneum when compared to the commonly employed air-impermeable plastic films. Resolution of preexisting IAD occurred in 8 out of 12 patients when switched from a traditional design to the redesigned absorbent brief.

What does this mean for me and my practice?

This redesigned brief lowered the surface pH and increased air-permeability in patients with or deemed at risk for IAD. Additional research is needed to determine the efficacy of this brief when compared to other products. Nevertheless, the data in this study clearly point out that briefs can be redesigned in ways that help to prevent or alleviate IAD in vulnerable patients.

C42. The Hygienic Effectiveness of 2 Different Skin Cleansing Procedures

Rönner A, Berland C, Runeman B, Kaijser B. Journal of Wound, Ostomy and Continence Nursing. 2010;37(3):260–264.

Article Type: Research study

Description/Results:

* Using 45 healthy adult volunteers, a solution of test bacteria, either Escherichia coli or Staphylococcus aureus, was applied to both forearms of the test subject. After a 15-minute incubation period, one arm was cleaned using soap and water and the other arm was cleaned with no-rinse cleanser. Both the arms were dried with a disposable cloth. The amount of residual bacteria on the skin was assessed using contact agar plates.

* Both the wash cream and the soap used in this study are free of any disinfecting agent (such as triclosan, parachloroxylenol, chlorhexidine, etc) that might irritate the skin with repeated use. It is hypothesized that the high levels of bacterial reduction are achieved primarily by mechanical removal of the bacteria.

* Both washing procedures resulted in equally low levels of residual bacteria on the skin.

What does this mean to me and my practice?

No-rinse cleansers are an excellent alternative to soap and water especially when repeated washing is indicated in the frail elderly person with fecal or urinary incontinence.

C43. Factors Influencing Intact Skin in Women With Incontinence Using Absorbent Products: Results of a Cross-sectional, Comparative Study

Shigeta Y, Nakagami G, Sanada H, Konya C, Sugama J. Ostomy Wound Management. 2010 Dec;56(12):26–33.

Article Type: Research study

Description/Results:

* 45 elderly women wearing absorbent incontinence products in a long-term care facility in Japan were divided into 2 groups: those with both fecal and urinary incontinence or dual incontinence (DIG) and those with fecal incontinence (FIG). Measurements of skin hydration and skin pH were higher than normal in both groups but were significantly higher in the DIG.

* Skin properties of the buttocks among elderly women with incontinence were affected by occlusion with pads suggesting that pads could contribute to skin damage.

What does this mean to me and my practice?

Efforts to improve absorbent pad performance and/or develop pH-balanced or antibacterial pads, as well as studies to establish a prevention protocol for maintaining healthy skin in the pad-occluded areas, are needed. More frequent pad changes as well as protective skin products may improve outcomes in prevention of incontinence-associated dermatitis.

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Indwelling Catheters

C44. Healthcare Infection Control Practices Advisory Committee. Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009

Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA. Infection Control Hospital Epidemiology. 2010 Apr;31(4):319–326.

Article Type: systematic review

Description/Results:

* Provides an evidence-based guideline which explores the following 3 questions: Who should receive urinary catheters? For those who may require urinary catheters, what are the best practices? What are the best practices for preventing CAUTI associated with obstructed urinary catheters?

* The Summary of Recommendations is organized as follows: (1) recommendations for who should receive indwelling urinary catheters (or, for certain populations, alternatives to indwelling catheters); (2) recommendations for catheter insertion; (3) recommendations for catheter maintenance; (4) quality improvement programs to achieve appropriate placement, care, and removal of catheters; (5) administrative infrastructure required; and (6) surveillance strategies.

What does this mean to me and my practice?

The WOC nurse should be part of the health care team to establish institutional policies and education for staff in the use of indwelling urinary catheters. This guideline provides a thorough review of the evidence to use in assuring that care is safe and risk of CAUTI is minimized.

C45. Reducing Catheter-Associated Urinary Tract Infection in the Critical Care Unit

Gray M. AACN Advanced Critical Care. 2010;21(3):247–257.

Article Type: Integrative review

Description/Results:

* Implementation of a program to decrease the use of catheters in the ICU can greatly reduce the incidence of hospital-acquired CAUTI.

* This program should define policies and systems for indwelling catheter insertion and the prompt removal of catheters when their use is not absolutely necessary.

* An assessment of available urinary catheters and viable alternatives such as external collection devices in males and selected use of intermittent catheterization in women and men should be part of the program.

What does this mean to me and my practice?

This article provides a thorough discussion of the evidence surrounding the consequences of the use of indwelling urinary catheters in the ICU. The WOC nurse should be part of the team to consider alternative ways to decrease both the frequency and duration of use while still providing optimal emptying of the bladder and accurate measurement of urine output.

C46. Study on the Use of Long-term Urinary Catheters in Community-Dwelling Individuals

Wilde MH, Brasch J, Getliffe K, et al. Journal of Wound, Ostomy and Continence Nursing. 2010;37(3):301–310.

Article Type: Research study

Description/Results:

* 43 persons with indwelling catheters (urethral and suprapubic) were recruited from a home health agency and from persons with spinal cord injuries via the Internet for a repeated-measures study (retrospective at intake and prospective at 2, 4, and 6 months) to describe over time catheter practices in long-term urinary catheter users and their catheter-related problems.

* Catheter-associated urinary tract infection was reported by 70%, blockage by 74%, leakage by 79%, and accidental dislodgement by 33%.

What does this mean to me and my practice?

Problems associated with long-term indwelling catheter use may contribute to excess healthcare utilization adversely affecting both users and their families. This article provides insight into the scope of the problem of living with a long-term indwelling catheter from both the physical and quality-of-life perspective.

Copyright © 2011 by the Wound, Ostomy and Continence Nurses Society

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