Urinary incontinence (UI), the complaint of involuntary loss of urine from the bladder, is prevalent and impacts health-related quality of life in many individuals.1 Although UI can be found in both males and females, it is more widely reported in females. According to Aoki and colleagues,2 there is a broad variation of UI prevalence in the literature, but converging studies suggest an approximate prevalence of 30% occurring in adult females. Unfortunately, due to possible feelings of embarrassment or a lingering social stigma, its true incidence in both sexes is likely underreported and many individuals fail to seek professional health care.
The RN or advanced practice registered nurse (APRN), who is board certified in continence care by the Wound, Ostomy and Continence Nursing Certification Board (WOCNCB), is influential in addressing the unique management of UI based on the foundation of lifestyle modification, education, and pelvic muscle reeducation. The Certified Continence Care Nurse (CCCN) or Certified Continence Care Nurse-Advanced Practice (CCCN-AP) are recognized experts in the first-line treatments of UI of all types and can make a significant impact on patient quality of life by implementing evidence-based continence care.
There are many risk factors associated with UI. Some risk factors are exclusive to a biologic sex, while others are associated with particular medical conditions. For instance, stress urinary incontinence (SUI) is frequently accompanied by urethral hypermobility and pelvic organ prolapse (POP). According to Baessler and colleagues,3 approximately 55% of women with stage 2 POP (prolapse to the hymen ±1 cm) have SUI. Urinary incontinence following radical prostatectomy surgery has a prevalence ranging from 2% to 60% in males.4 For individuals born with myelomeningocele, one of the most severe forms of spina bifida, management of neurogenic lower urinary tract function (usually including UI) profoundly impacts overall health-related quality of life and social well-being. Urinary incontinence in older adults is often multifactorial, with the aging urinary tract, multiple comorbid conditions, and functional impairments cited as contributing factors. According to McDaniel and colleagues,5 UI rates are likely to persist as the US population continues to age.
The management of UI includes behavioral, pharmacologic, surgical, and bundled interventions. Conservative (behavioral) strategies include weight loss measures, pelvic floor exercises, and fluid or diet modifications such as decreasing or eliminating caffeine; adding fiber to the diet to decrease constipation; or limiting fluid intake in the evening before bedtime. In addition, behavioral modification programs may be instituted and educational resources provided to patients and/or caregivers on such techniques as urge suppression strategies and scheduled voiding regimens. The goals of UI treatments are to reduce or stop episodes of involuntary urine leakage and improve health-related quality of life.
Due to the extensive preparation required to become WOCNCB certified in continence care, this specialized nurse clinician holds a breadth of knowledge, management, and clinical skills to improve the outcomes of those patients suffering with these health care concerns. Besides providing education and counseling to patients, families, caregivers, and other members of the health care team on understanding, managing, and preventing incontinence issues, the CCCN or CCCN-AP plays a pivotal role in performing assessments, evaluations, and interventions that directly impact the course of the patient's overall treatment plan. These clinicians may be responsible for appropriate selection, fitting, and management of a continence pessary for a patient suffering with SUI; conducting and/or interpreting urodynamic studies for mixed UI symptoms; and developing and managing individualized toileting and containment strategies for individuals experiencing functional UI.
Certifying in one's specialty discipline as a professional nurse demonstrates public recognition of the essential knowledge and skills obtained to establish and guide evidence-based decisions in that area of practice. The WOCNCB continence certification exam is offered at the RN, CCCN, or CCCN-AP levels and is based on core content that is foundational to continence care principles and treatment modalities. Examination preparation, organization, and review of the content outline are critical components for exam success.
The review questions presented here focus on first-line continence care found in daily practice. Without looking at the answer or the rationale, attempt to answer the question. The question rationale will facilitate your review of content as well as polish your test-taking skills. To learn more about how to prepare for certification as a CCCN or CCCN-AP, please visit the content outline for the CCCN or CCCN-AP available on the WOCNCB Web site: http://www.wocncb.org.
PRACTICE QUESTIONS
Certified Continence Care Nurse (CCCN) Review Questions
1. A 56-year-old male patient with chronic lower urinary tract symptoms and recently diagnosed benign prostatic hyperplasia (BPH) presents at the clinic with complaint of an inability to void. His postvoid residual measures 700 mL. As the CCCN, what would you expect to teach this patient before he leaves the clinic?
- Bladder training technique
- Medication administration
- Pelvic floor muscle exercise
- Intermittent catheterization
Content outline domain: 020109
Cognitive level: Application
Answer D:
Rationale: Intermittent catheterization would be the expected treatment of acute obstruction secondary to BPH. Bladder training, option A, is incorrect, as this is a classic treatment in the behavioral therapy process for the management of urgency and urgency incontinence. Option B, medication administration, is incorrect because, although medications are often used in the management of BPH, once the patient has acute obstruction, the patient has failed conservative treatment that otherwise might include medications, specifically α-adrenergic blockers or 5α-reductase inhibitors, or behavioral interventions such as restricting drinking fluids right before bed. Stress urinary incontinence is generally a result of a compromised urethral sphincter that allows urine to flow from the bladder involuntarily. Pelvic floor muscle exercise, option C, is a first line treatment of SUI that strengthens muscles that control unintended urinary outflow with increased abdominal pressures.
Review Questions 2 and 3 Apply to the Following Patient's Case:
2. The CWOCN receives a consult to evaluate a 78-year-old woman, hospitalized for pneumonia, regarding UI with skin breakdown. A head-to-toe assessment reveals a thin, pleasant, confused, elderly female with intact skin except over the perineal area. The skin is hyperpigmented with reddened areas and scattered, shallow erosions with pink bases, and irregular margins deep in the creases. The affected area extends from the groin folds anteriorly and involves the external genitalia and the gluteal cleft posteriorly. The patient reports pain in those areas. What type of intervention for the incontinence-associated skin damage would the CWOCN implement or recommend for this patient?
- Nystatin powder and plastic-lined briefs
- Absorptive foam dressings and a catheter
- Thin film dressings and a wound culture
- Cleansing wipes and a barrier ointment
Content outline: 020108
Cognitive level: Application
Answer D:
Rationale: In order to treat and prevent further damage from the patient's incontinence related to incontinence-associated dermatitis, the CWOCN would need to implement gentle cleaning, moisturizing with an emollient, and protecting with a skin barrier. Cleansing wipes may cleanse and moisturize or provide all 3 actions with a single step. Nystatin powder and plastic-lined briefs, option A, is incorrect because this patient's assessment revealed no indication of fungal involvement, which would classically include satellite lesions, peeling, or itching. The option of body-worn absorbent products is excellent for providing patient dignity, but the plastic lining included in distractor A is not breathable and therefore not recommended as it will put the patient at risk for further damage to the skin by holding in moisture and increasing friction. Absorptive foam dressing and a catheter, option B, is incorrect because foam dressing is not the recommended intervention for this type of skin injury as it could hold moisture next to the skin, would be difficult to keep in place in a fold, and would become soiled with each toileting episode. The catheter also makes this answer incorrect as the risk of catheter-associated urinary tract infection and increased fall risk are not desirable in a functional, older patient with incontinence. Option C, thin film dressing and wound culture, is incorrect in that the application of thin film dressing in this situation would likely make the skin injury worse by contributing to the moisture in the area. Adhesive dressings can also be ineffective in this area in general. Wound culture is incorrect as the patient has no evidence of infection as there was no mention of fluctuance, heat, or odor after cleansing in the assessment.
Certified Continence Care Nurse-Advanced Practice (CCCN-AP) Review Question
3. A 58-year-old, obese postmenopausal female with a past medical history of hypertension and obstetric history of 3 normal vaginal births presents for a follow-up visit regarding her UI. She has recently started a weight loss program and pelvic muscle exercises (Kegel exercises) and has modified her fluid intake volume as well as reducing bladder irritants. She reports sleeping through the night with improved daytime urinary frequency and urgency. Her major complaint is continued small-volume urine leakage with jogging and strong cough and requests medication to “fix it.” What would be an appropriate next step in her treatment?
- Start Oxybutynin IR 5 mg daily.
- Start Mirabegron 25 mg daily.
- Review pelvic muscle exercise technique and teach her the “Knack.”
- Refer to urology/urogynecology for urethral bulking procedure.
Content outline: 4C2e
Cognitive level: Analysis
Answer C:
Rationale: The correct answer to this question is to review with the patient her pelvic muscle exercise technique and instruct her in doing the “Knack.” Major professional groups, such as the American Urological Association/Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (AUA/SUFU), have published guidelines for the treatment of incontinence that recommend a tiered approach to treatment. The first tier includes lifestyle modifications and exercise of which the question stem clearly indicates has been started. Pelvic muscle exercises involve a program of daily and progressive exercises requiring correct technique to be effective and in which a reevaluation would be a very reasonable first approach. Adding the “Knack” or stress maneuver to her plan of care will help decrease and often help avoid leakage prior to activities that increase intra-abdominal pressure. The question stem does not specifically state a diagnosis but indicates the patient has seen significant improvement in symptoms of urgency, frequency, and nocturia with lifestyle modifications. Her chief complaint at this time is leakage with jogging and strong cough, both strongly indicating stress incontinence for which medications listed in options A and B would not be effective because both medications treat overactive bladder (OAB)/urge incontinence. Oxybutynin IR is an antimuscarinic in an immediate release (IR) formulation, making once-a-day dosing not optimal to manage 24-hour symptoms. Mirabegron is a β3-adrenoceptor agonist that functions to manage OAB symptoms such as urgency, frequency, and nocturia; yet, these symptoms are not addressed as the major complaint in the question. Referral for urethral bulking procedure would certainly be indicated if a patient does not respond to lifestyle modifications and pelvic muscle exercises.
