Preparing for continence certification involves a comprehensive review of each type of urinary incontinence, which will help the testing candidate move efficiently and confidently through the certification exam. The continence certified nurse must be able to identify key assessment findings, differentiate symptoms, and determine the best treatment options. Expert assessment and accurate diagnosis of incontinence lead to a tailored management plan for the patient.1
A patient reporting leakage of urine on “effort or exertion” in the absence of urgency to void quickly alerts the continence certified nurse that the patient may have stress urinary incontinence.2 Increased abdominal pressure with associated urethral hypermobility or intrinsic sphincteric deficiency prevents the sphincter muscles from maintaining urethral closure during activities, such as coughing, sneezing, and high-impact exercising.3 Stress incontinence is common in women, and men may experience stress incontinence after radical prostatectomy.4
When preparing for certification examination, quickly identifying the type of incontinence and the first line of management for each type will assist the candidate to eliminate incorrect responses. Understanding the implications of the previous treatments, medical history, mental status, body mass index (BMI), mobility, and comorbid diseases will help the candidate know which treatment modality makes the most sense to offer first.2
The following questions assess continence-educated nurses' ability to identify stress urinary incontinence and different management options they might offer depending on the presentation of their patients. These items are related to the exam outline “Domain III: Continence Care, Task 3: Assess and Manage Stress Incontinence.”5
1. A 10-month postpartum woman reports urinary leakage during her gym workouts. She reports adequate hydration and drinks 1 cup of coffee per day. Physical assessment reveals the patient is at her pre-pregnancy weight with a BMI of 24. To manage her incontinence, she urinates immediately prior to working out and uses body-worn absorptive products during exercise. What recommendation would the continence nurse provide at this time?
- Continue use of body-worn absorptive products
- Pelvic floor muscle exercises
- Referral for surgery with a urogynecologist
- Limit fluid intake 1 hour prior to exercise
Cognitive level: Analysis
Rationale: The continence nurse quickly identified the woman as experiencing stress urinary incontinence based on the patient's report of exercise-induced leaking. The continence nurse recognizes vaginal delivery as a risk factor for stress urinary incontinence due to weakening of the pelvic floor muscles. While body-worn absorptive products protect the skin and prevent embarrassment, they do not treat the underlying cause of stress urinary incontinence. First-line treatment of stress incontinence includes strengthening the pelvic floor muscles to increase underlying support of the urethra and prevent urine leakage associated with increases in intra-abdominal pressure during exercise. Referral for evaluation for surgical intervention such as a mid-urethral sling procedure would be appropriate but only after first-line treatment has been tried. Decreasing fluid intake prior to exercise may decrease the volume of urine leakage but does not address or treat the underlying cause of the patient's stress incontinence. The best recommendation the continence nurse can make in this scenario is to instruct the patient in pelvic floor muscle exercises.
2. A 62-year-old male patient is seeking advice about his urinary leakage 3 months after a prostatectomy. He has been following the daily exercise protocol prescribed to him for strengthening his pelvic floor and reports that he feels there is little difference in his incontinence. Which management option is best for the patient?
- Explain that it is common to experience an irritable bladder with urine leakage after prostatectomy.
- Provide referral for urethral percutaneous tibial nerve stimulation (PTNS).
- Provide referral for implantation of an artificial urinary sphincter.
- Assist him in selecting a body-worn absorptive product such as a male guard or pouch.
Cognitive level: Application
Rationale: The patient is most likely experiencing stress urinary incontinence, which is common after prostatectomy. The continence nurse understands that it may take up to 6 months for the rhabdosphincter to recover its strength and endurance. The best management option would be to assist him in choosing a body-worn absorptive product that is designed for male urinary incontinence such as a male guard or pouch. It would also be appropriate to encourage him to continue with his pelvic muscle exercises. It would be premature to refer the patient for surgical implantation of an artificial sphincter. It is recommended that patients who experience urinary leakage after prostatectomy employ conservative treatments such as pelvic muscle exercises and fluid management up to 6 to 12 months after surgery. Percutaneous tibial nerve stimulation is considered a tertiary intervention for urgency incontinence. The continence nurse's role in the patient's plan of care is to help him choose appropriate and effective body-worn absorptive products until bladder control returns.
ADVANCED PRACTICE QUESTION
3. A 48-year-old woman reports increasing urine leakage associated with walking, playing tennis, and gardening. Physical examination reveals movement of the urethra and urine leak with cough. There is no prolapse, and examination of the pelvic floor muscles shows a strong circumferential squeeze of the examining finger moving the examining finger up and into the vagina, squeeze endurance of more than 3 to 4 seconds, and isolated muscle contraction. The patient reports doing her Kegel exercises 3 times a week. What is the next step for the treatment of her incontinence?
- Counsel patient to avoid activities that increase intra-abdominal pressure.
- Offer a fitting for an incontinence pessary to use with exercise.
- Recommend treatment with a beta-3 adrenergic agonist.
- Counsel the patient to stop pelvic muscle exercises due to ineffectiveness.
Cognitive level: Analysis
Rationale: The correct answer is to offer the patient a fitting with an incontinence pessary. Analysis of the information supplied in the question stem supports this decision for pessary fitting, given that the patient most likely has urethral hypermobility, which has not been impacted by first-line treatment with pelvic muscle exercises. Assessment information observed movement of the urethra and a positive cough leak test, which is diagnostic for urethral hypermobility. An incontinence pessary is an open ring with a knob on one end that is fitted to support the urethra and bladder neck and can be very effective in reducing and, in some cases, eliminating stress incontinence. It would not be realistic to ask this patient to avoid activity that increases intra-abdominal pressure, especially given that regular exercise contributes to overall health, helps avoid weight gain, and contributes to pelvic health. Beta-3 adrenergic agonists are not indicated for stress incontinence but indicated only for overactive bladder symptoms such as urgency incontinence, frequency, and nocturia. Counseling the patient to stop doing pelvic muscle exercises is counterproductive. The patient in this case was assessed to have adequate pelvic muscle strength, endurance, and isolation, and it is likely that her pelvic health is contributing to her current level of continence.