On July 12 and 13, 2002, dozens of nurses and others with expertise in incontinence research, education, administration, and clinical practice gathered in Philadelphia for a day-long symposium, “The State of the Science on Urinary Incontinence.” Organized by the University of North Carolina-Chapel Hill School of Nursing; the Penn Center for Continence and Pelvic Health, Division of Urology, the University of Pennsylvania Medical Center; and AJN, in collaboration with the Center for Professional Development, the University of Pennsylvania School of Nursing symposium was designed to address the state of the art and science of continence promotion and the prevention, assessment, treatment, and management of urinary incontinence (UI), especially in vulnerable groups such as the elderly. In addition to reviewing information that can serve as a foundation for evidence-based nursing care of people with incontinence, the symposium aimed to identify barriers to optimal care and to make recommendations for nursing research, clinical care, education, and policy.
Symposium attendees heard brief presentations from the authors of the four main papers in this supplement. Carolyn Sampselle, PhD, RN,C, FAAN, spoke about incontinence in young and middle-age women. Mikel Gray, PhD, CUNP, CCCN, FAAN, presented an overview of gender, racial, and cultural issues. Jean Wyman, PhD, APRN, BC, FAAN, reviewed treatment in men and older women. Deborah Lekan-Rutledge, MSN, RN,C, CCCN, discussed UI in the frail elderly.
At the end of each presentation, participants worked in small groups to identify barriers related to the topic and to recommend ways to overcome them. In a plenary session late in the day, participants reviewed the barriers that they had identified, made recommendations, and discussed critical aspects of incontinence management that hadn’t been addressed.
See page 5, in the Executive Summary, for a list of the barriers to optimal continence identified by the participants. Some of the barriers generated extensive discussion.
A major barrier to tackling incontinence is that researchers have used different definitions, ranging from slight involuntary urine loss to leakage that necessitates behavioral management or the use of devices to collect urine. What’s needed is a universally acceptable definition that describes the severity of incontinence in several ways:
- amount of urine loss (such as drops or enough to soak underwear)
- frequency of involuntary urine loss (for example, several times a day or once or twice a week)
- timing; when the problem occurs (for example, during exercise or on the way to the bathroom)
- coping strategies the patient uses (for example, does he decrease fluid intake or plan days around places where toilet facilities are known to be located)
Armed with a definition in clear, simple terms, clinicians may find it easier to raise the subject of UI with patients. However, language barriers can still interfere. For example, as one nurse told symposium colleagues, a clinician might use the word “leak” to form a question about involuntary urine loss. But a patient, thinking of the expression “take a leak,” may assume that the nurse is talking about intentional voiding. Others observed that young women with stress incontinence or minor urine leakage may deny being incontinent; they may not be greatly inconvenienced and further, they may consider incontinence to be a problem mainly of older women. In order to facilitate communication about this sensitive subject with patients of all ages, sexes, and ethnic groups, nurses need to hone their language skills and be cognizant of their personal responses to incontinence.
Misinformation and misconceptions.
Several items on the list of barriers begin with “lack of knowledge.” Health care professionals, patients, and others whose actions influence continence management (such as third-party payers) all are missing important information about bladder health and UI.
Symposium participants recognized that although education is necessary, it’s not enough—changes in attitudes, beliefs, and values also are essential. Both the general public and health care providers often fail to recognize that incontinence is an important health concern and, because of its prevalence, a significant public health issue.
A top priority that emerged during the symposium was the need to educate the public about bladder health. Unknowingly, people may increase their risk of developing incontinence by actions such as limiting fluid intake or holding their urine for long periods of time. As the articles in this supplement demonstrate, incontinence is a major health problem for men as well as women, young as well as old, and people of all ethnic backgrounds. The knowledge that effective treatment exists will encourage patients to discuss the problem with their health care providers.
For many people, however, bladder function remains a subject not to be mentioned in polite conversation. Deeply rooted cultural taboos make members of some ethnic groups particularly reticent to discuss bladder issues. For this reason, nurses need to approach continence education in a way that is culturally acceptable and remove stigmas associated with the issue.
Nurses and other health care providers may harbor the same misconceptions and negative feelings about incontinence as the general public. To provide quality care, clinicians must understand the causes of UI, risk factors, and the effectiveness of specific interventions for various populations.
In addition to the misperception that incontinence is a minor issue, several barriers hamper nurses’s efforts to perform routine incontinence screening and assessment:
- lack of validated assessment and diagnostic tools that can be used for men and women of all ages, races, and ethnic backgrounds
- time constraints
- inadequate third-party reimbursement
Nurses are capable of screening and assessing people for incontinence, instituting behavioral interventions, providing bladder or pelvic muscle retraining, and suggesting appropriate products and devices as management options. Advanced practice nurses routinely prescribe drug therapy for incontinence. A major challenge lies in convincing physicians, institutions, policy makers, and third-party payers that nurses can handle these essential roles and that their expertise should be valued and reimbursed.
In addition, participants noted that institutional settings might lack a full spectrum of products and devices for managing UI. Institutional purchasing decisions may limit what is available; better products or devices could improve continence management and reduce overall costs of care.
The group noted an abundance of descriptive research on UI. The next step is for nurse researchers to design comprehensive clinical trials that can lead to the development of evidence-based practice and guidelines. Because incontinence has erroneously been considered a problem of older women only, most research has focused on this population. However, anyone—old or young, female or male—can develop incontinence. It’s not known whether an approach that works well in older women will be as effective in men or in younger women or whether cultural differences may necessitate different strategies for members of different ethnic groups.
Furthermore, the participants observed a disparity between research and practice. Research findings don’t always translate readily to use in hands-on clinical care.
The complete list of recommendations generated by the symposium participants is on page 7, in the Executive Summary. Many of the barriers identified by participants led directly to recommendations. For example, rather than speaking exclusively about incontinence, symposium attendees called for, and immediately began using, the terms “continence care” and “bladder health.” This alternative language stresses that the health of the bladder is a priority for everyone, regardless of age or background. Every continent person is a potentially incontinent person.
Public awareness campaign.
Symposium attendees called for a mass media campaign to raise public awareness and to lift the veil of embarrassment about incontinence. Two successful public awareness campaigns—erectile dysfunction and breast cancer awareness—can serve as models. An awareness campaign should involve frank and frequent discussion of bladder health in popular magazines, newspapers, radio, and television. The mass media campaign would have several goals:
- raise awareness about bladder health and incontinence
- provide basic information
- correct misconceptions
- change attitudes
- inform the public about treatment options, including behavioral techniques.
Given the diverse purposes of the public awareness campaign, a variety of spokespeople can carry the message: nurses and other health care professionals, community opinion leaders, and celebrities. We may already have one celebrity spokesperson—actress Debbie Reynolds recently spoke about her personal experiences related to bladder health at A Women’s Forum: Lifelong Pelvic and Bladder Health, held in Houston and sponsored by the National Association for Continence.
In some ethnic groups, community involvement is especially important. Reluctance to discuss bladder issues may be overcome more easily if community leaders talk freely about the subject in a culturally acceptable manner. Educating the public may entail taking the message to places where members of a group gather, whether in churches, beauty shops, or social venues.
The mass media approach to educating the public will also help to correct nurses’ knowledge deficits. In addition, professional journals and research publications need to translate incontinence research into information that is relevant to practicing clinicians. Training in incontinence care is only a small part of the formal nursing education. Both undergraduate and graduate nursing curricula should include units on assessment and management of UI. Continuing education programs on continence care for practicing nurses and nurse educators are essential. Finally, for nurses with a special interest in this area, advanced training is desirable. Training more nurses as specialists in continence care will increase competence in bladder health and should improve patient outcomes. Whatever the practice setting—acute care, primary care, home care, long-term care, or in practices with specialists such as urologists and gynecologists—advanced practice nurses can serve as peer educators and mentors of nursing staff.
A major outcome of the Philadelphia symposium was the identification of research priorities, the goal of which is to provide information that can bring about positive changes in nursing practice. Particularly important areas for further research include
- the prevalence and nature of UI in groups that haven’t been well studied, including men, young women, and members of minority groups.
- universally appropriate assessment strategies.
- the effectiveness of various behavioral techniques, devices and products for managing urine leakage, and pharmacotherapy, alone and together, in each subgroup of patients with incontinence.
- the effectiveness of primary prevention strategies.
- alternative models for educating and using staff in primary care and long-term care settings for improved management of incontinence.
To overcome barriers to implementing study results, researchers and clinicians need to work together to develop evidence-based procedures. Inclusion of clinicians, opinion leaders from various ethnic groups, and health economists on research teams will result in clinically relevant studies. Evidence-based guidelines should be culturally sensitive, relevant, and simple enough for all clinicians to use. Where they don’t already exist, site-specific interdisciplinary guidelines (such as a unique set of practice guidelines for nursing homes) may be desirable.
More research is needed on the pharmacokinetics of medications in the frail elderly and the interventions that are most likely to benefit these patients. Creative technological approaches may result in development of better incontinence devices, including user-friendly products and substitute toilets.
Cost-effectiveness research may be able to demonstrate that nursing-based continence care is cost-effective. Such research may be necessary to ensure reimbursement for all aspects of continence care by nurses: screening, for all age groups; evaluation and management; behavioral intervention; and preventive education in the primary care setting.
Incontinence care in nursing homes requires careful scrutiny. Optimal continence care in this setting is often compromised by high turnover of nursing staff and lack of training in continence management. Symposium attendees suggested several institutional changes that may reverse this trend:
- an onsite advanced practice nurse dedicated to continence care, who would be a resource for other staff
- function-based nursing, with certified nurse aides (CNAs) dedicated to continence care
- multidisciplinary programs that involve the entire staff, including CNAs, the director of nursing, the medical director, housekeeping, maintenance, dietary, and other staff
- holistic models of incontinence care addressing the physical, psychological, and social components of residents.
Incontinence can affect the quality of life of people of all ethnic backgrounds and any age. Both patients and health care providers lack knowledge about bladder health, which presents a major barrier to optimal continence. While research is under way to find information that will fill current knowledge gaps, nurses can help by raising awareness and comfort with bladder health. Routine screening of all patients is an important step in identifying bladder control and incontinence problems.
Symposium attendees observed that no single health care profession has taken the initiative for incontinence care and continence promotion. Certainly, within nursing, the Society of Urologic Nurses and Associates; the Wound, Ostomy and Continence Nurses Society; and the Association of Women’s Health, Obstetric and Neonatal Nurses have provided leadership on this issue, but a broader collective effort by nursing is needed to move continence care forward.
Drugs used to treat incontinence.
Medications play an important role in the treatment of urinary incontinence and overactive bladder. Extensive research and clinical studies have supported the role of pharmacological agents as part of first-line medical therapy.
Symposium participants recognized that the papers presented barely mentioned what is already known about the efficacy of medications to prevent and manage incontinence. However, while several of the symposium recommendations were designed to encourage the profession to address this omission, a number of existing studies and review articles provide a beginning foundation for examining what we know about pharmaceutical approaches to managing incontinence.
Pharmacological treatment is most often directed at two types of incontinence
- Stress urinary incontinence (SUI), the involuntary loss of small amounts of urine during coughing, sneezing, laughing, and physical exertion.
- Urge urinary incontinence (UUI), the loss of larger amounts of urine that is usually precipitated by urinary urgency (strong sudden urge to void), frequency (voiding more than eight times in a 24-hour period), and nocturia (awakening at night to void). Overactive bladder (OAB) symptomatology includes urgency, frequency, and nocturia with or without urge incontinence.
Drugs for SUI have targeted the urinary sphincter. Sympathomimetic drugs with alpha-adrenergic agonist actions were found in over-the-counter medications such as Sudafed. However, the effective ingredient was phenyl phenylpropanolamine, which is no longer available in these drugs. Topical estrogen administered by the vaginal route may be beneficial in treating SUI, especially when urogenital atrophy is a likely factor. 1 Forms of topical estrogen include cream (Premarin, Estrace), tablets (FemTabs), and a vaginal ring (Estring). Duloxetine, a combined serotonin and noradrenaline reuptake inhibitor, is currently under review by the Food and Drug Administration (FDA) as an agent for increasing neural activity to the urinary sphincter. 2 Serotonin and norepinephrine are neurotransmitters found in the external urinary sphincter; increased activity of these transmitters can result in contraction of the sphincter, thus preventing SUI.
Drugs for UUI and OAB include anticholinergic (antimuscarinic) agents. 3 The bladder is a smooth muscle that contains muscarinic (M2 and M3) receptors that are responsible for contractions. 4 Muscarinic receptors are also distributed throughout the entire body; for example, the parotid gland is heavily mediated by M3 receptors, which accounts for the significant dry mouth that many people experience when taking non-specific anticholinergics. 5 Drugs that are indicated for UUI and OAB are immediate-release (IR) oxybutynin, oxybutynin extended release (Ditropan XL), tolterodine immediate and tolterodine extended release (Detrol and Detrol LA, respectively). 6–10 IR oxybutynin has been available for over 30 years. Although its ability to inhibit involuntary contractions of the bladder has been proven, the problem with it is poor patient compliance due to side effects. 11,12 Because IR oxybutynin’s M3 selectivity isn’t specific to the bladder, it tends to affect other smooth muscle, causing side effects such as dry mouth, blurred vision, constipation, somnolence, and impaired cognitive function. 13 Antimuscarinics are contraindicated in patients with urinary retention or narrow-angle glaucoma. 14 Tolterodine and the newer formulation of oxybutynin have been shown to have fewer side effects. The future of pharmacologic treatment for UUI is bright as there are more agents under investigation (darifenacin, trospium) or review by the FDA (transdermal oxybutynin). 15,16 —Diane K. Newman, MSN, RNC, CRNP, FAAN, is codirector at the Penn Center for Continence and Pelvic Health, Division of Urology, University of Pennsylvania Medical Center, Philadelphia.
Which Surgery Is Best?
The goal of the Urinary Incontinence Treatment Network is to find out.
Surgery to reposition or stabilize the bladder neck and proximal urethra has been a common treatment for women with stress urinary incontinence. However, the efficacy and long-term outcomes of the various surgical procedures have not been examined in head-to-head comparisons. That is about to change.
The Urinary Incontinence Treatment Network (UITN) is a consortium of investigators, mainly urologists and urogynecologists, from nine continence treatment centers across the country. A biostatistical coordinating center, New England Research Institutes, is also part of the consortium. The primary goal of the UITN is to assess the long-term outcomes of the most common treatments for women with stress and mixed urinary incontinence. The first study of the UITN is a randomized clinical trial comparing the treatment success, at a minimum of 24 months after surgery, of two surgical procedures, the Burch (modified Tanagho) procedure and the autologous rectus fascia sling procedure.
Both the Burch procedure and the sling procedure have been used for several decades as primary treatment for women with stress urinary incontinence. Cure rates for both procedures of about 60% to 90% have been reported in the medical literature. 1 However, it’s unclear whether one procedure is better than the other and should be offered to all women with stress incontinence. The UITN study, which will enroll 650 women, aims to answer that question. Study enrollment began in early 2002. Results should be available in 2006.
The UITN is funded, for five years, by the National Institute of Diabetes and Digestive and Kidney Diseases in collaboration with the National Institute of Child Health and Human Development. Nursing is very much involved in this project. Most of the study coordinators in the nine UITN sites are nurses.—Jan Baker is a family nurse practioner and a Urinary Incontinence Treatment Network (UITN) coinvestigator in the division of Urogynecology and Pelvic and Reconstructive Surgery, Department of Obstetrics and Gynecology at the University of Utah in Salt Lake City.
The Use of Devices and Products
Know the tools of managing urinary incontinence.
Products such as absorbent pads and external urethral barriers, and devices such as catheters, intraurethral inserts, intravaginal pessaries, and urinals, are integral to the management of urinary incontinence (UI), especially intractable UI. 1 Containing or collecting urine, avoiding complications such as skin breakdown, and enabling the incontinent person to maintain daily activities, dignity, and quality of life are the primary objectives in using UI products and devices. 2 Specially designed products and devices for management of UI are a growing market and contribute a significant amount to overall UI costs. 3 Caring for persons with “elimination problems” has been integral to basic nursing care since Florence Nightingale’s time. 4 Nurses should recommend specific products and devices only after doing an individualized assessment and discussing the patient’s preferences. Little nursing research has been conducted on the use of UI products and devices, and few publications discuss clinical applications.
Absorbent products, which may be disposable or reusable, are the most common type of product for containing urine leakage. Perineal pads and panty liners are absorbent products suitable for slight leakage. Products for moderate-to-heavy leakage include undergarments and protective underwear, guards and drip collection pouches for men, and diapers (called adult briefs). In addition, nonwearable absorbent pads may be used to protect the bed and furniture.
Most products are used by women with UI. Unlike feminine hygiene products designed to absorb menstrual blood, wearable disposable absorbent incontinence products are designed specifically to absorb and contain urine. The UI products consist of wood pulp and a polymer that absorbs and binds with the urine, changing it into a gel. 2 The gel minimizes urine leakage and odor. These products keep the urine away from the perineal skin, quickly transmitting the urine to an absorbent inner core that locks in the wetness and thus promotes dryness. 5 Absorbent products should never be used solely for the convenience of the caregiver. Adverse effects include skin irritation.
External urethral barriers were developed to prevent rather than absorb urine loss in women with mild-to-moderate stress UI. One such device was a small, triangular foam pad with a layer of adhesive on one side to adhere over the urinary meatus. 6 Another design was a soft suction cup made of silicone, which was placed externally over the urinary meatal area to collect the urine leakage. 7 These products were developed for nonprescription sales, similar to absorbent products. However, due to lack of consumer and provider interest, they are no longer available in the United States.
Medical devices used for UI include catheters, intraurethral and intravaginal devices, and collection devices. Most of these devices are covered by third-party payers and need to be prescribed by a physician or nurse practitioner.
All catheters are available in multiple sizes and materials (latex, Teflon-coated, silicone, rubber). Nurses manage indwelling catheters, and the patient or caregiver usually performs intermittent catheterization and manages external catheter systems. The patient’s dexterity and compliance need to be considered when selecting a device. Ongoing assessment of the urethra, bladder, and genitalia is essential for any patient managed by catheters.
The appropriateness of indwelling catheters has been documented in the medical literature for short-term use in hospitalized patients. However, in other settings, such as long-term care and home-care settings, these devices are being used long-term (more than 30 days) to manage urinary retention and UI. Catheter use in patients requiring skilled nursing home-care visits increases overall costs and nursing visits and contributes to nursing care problems. 8
Clinical guidelines have been developed that indicate medical conditions appropriate for the use of long-term indwelling catheters 9–11 when urethral obstruction or urinary retention is present, with the following conditions:
- Persistent overflow UI, symptomatic infections, or kidney disease
- Surgical or pharmacologic interventions unsuccessful or inappropriate
- Contraindications to intermittent catheterization for retention
- When changes of bedding, clothing, and absorbent products may be painful or disruptive for a patient with an irreversible medical condition, such as metastatic terminal disease, coma, or end-stage congestive heart failure
- For patients with grade 3 or 4 pressure ulcers that are not healing because of continual urine leakage
- For patients who live alone without a caregiver.
The long-term use of an indwelling catheter increases the risk of mortality and morbidity secondary to complications, such as recurrent urinary tract infections leading to urosepsis, development of bladder stones and cancer, urethral damage in men secondary to urethral erosion, and urethritis or fistula formation. 12 Nursing care problems associated with long-term use of indwelling catheters include urine leakage around the catheter, blockage of the catheter system, inadvertent dislodgement (usually when the balloon is inflated), and inability to deflate the retention balloon. 13,14 Although nurses may find that indwelling catheters ease routine nursing care, patients find catheters uncomfortable and painful.
Periodic insertion of a sterile or clean catheter several times a day to empty the bladder is called “intermittent catheterization.” Clean intermittent catheterization has become the standard of care for self-catheterization in people with spinal cord injuries. 15 It may relieve symptoms such as UI, urgency, and nocturia. Complications include infection and urethral trauma, but such complications occur less frequently in patients managed by clean intermittent catheterization than in those with an indwelling catheter.
An external catheter system consists of a condom-type sheath that is placed over the penis. This system is suitable for men with moderate-to-severe UI and may also be used to manage urinary urgency or frequency when frequent trips to restrooms would be difficult. 2 Patients at a Veterans Administration medical center found the use of a condom catheter more comfortable, less painful, and less restrictive than use of an indwelling catheter. 16 As with other types of catheters, long-term use of external devices can lead to infection, penile skin maceration and irritation, and phimosis. If not carefully monitored, strangulation of the penile shaft could occur.
Intraurethral and intravaginal devices.
For stress UI, medical devices called “urethral inserts” can be placed in the urethra to block leakage. A urethral insert is a disposable, single-use device that is used by women during activity that causes urine leakage, such as playing tennis or golf. 17 Adverse effects include infection and hematuria.
An incontinence pessary is a mechanical device that is inserted into the vagina to support the bladder neck. The pessary has been used for centuries to support pelvic organ prolaspe. A recently developed incontinence pessary has been used effectively in women who leak urine during strenuous exercises and other physical activities. 18 Adverse effects include vaginal infection, low back pain, and vaginal mucosa erosion. Another problem is forgetting to remove the pessary.
A patient or caregiver can successfully use urine collection containers (such as urinals, bedpans, and commode chairs) once the proper device is identified. 2,19 These devices have received little attention as aids to contain urine.
The designs of women’s urinals that are available in the United States aren’t conducive to voiding in different positions. Another available external urine-collecting device for women is similar to an ostomy pouch. Despite research attesting to its clinical effectiveness in a rehabilitation setting, this pouch isn’t widely used. 20,21
FOR FURTHER INFORMATION
The National Association For Continence (NAFC) is a nonprofit organization “dedicated to improving the quality of life of people with incontinence.” NAFC publishes The Resource Guide of Products and Services for Incontinence. Now in its 12th edition, this excellent guide lists incontinence products and devices and their manufacturers, organizations that address incontinence, treatment options, and use of a voiding diary. With this guide, practicing nurses can help patients and family members learn more about UI and devices and products to manage it.
The guide is a benefit of membership in NAFC. Nonmembers can purchase it for $13.00 by contacting NAFC at 800-BLADDER (252-3337); [email protected]—Diane K. Newman, MSN, RNC, CRNP, FAAN, is codirector at the Penn Center for Continence and Pelvic Health, Division of Urology, University of Pennsylvania Medical Center, Philadelphia.