1. Managing Urinary Incontinence Post Stroke Telehealth Presentation for Alberta Provincial Stroke Strategy April 23, 2009
Laura Robbs, RN, BScN, MN, ET, NCA
Clinical Nurse Specialist-Continence, Trillium Health Centre
Mississauga, Ontario

2. Learning Objectives: Review normal bladder function
review common types of urinary incontinence
Discuss the impact of stroke on urinary continence
discuss strategies for promoting urinary continence post stroke

3. What is urinary incontinence (UI)?
It has been defined by the International Continence Society as:
“a condition where involuntary loss of urine is a social or hygienic problem”
(ICS, 1988)

4. Responses to UI: Fear embarrassment shame anxiety frustration guilt
anger

5. Relationship between UI & Quality of Life:
Greatest negative impact on emotional and social well being
UI is embarrassing, socially disruptive with multiple effects on daily activities and interpersonal relationships
does not appear to have devastating psychological consequences

6. Who is affected by UI? ↑ risk of falls, fractures & hospitalization
General population:
1 in 4 women
1 in 10 men
post stroke:
32-79% people on admission
25-28% on discharge
↑ risk of falls, fractures & hospitalization
triples the risk of long term care placement

7. Bladder function: Voluntary & reflexive control
Bladder - muscular balloon constantly filling under low pressure
Bladder stretch receptors send impulse through SC to the brain
stimulates a response causing bladder to contract & allows external sphincter to relax

8. Bladder function (continued):
Therefore urine is expelled as the bladder contracts, internal sphincter opens & external sphincter relaxes
Key: brain able to reduce urge and delay urination

9. Normal Micturition Cycle
Storage phase
Emptying phase
Bladder pressure
Normal Micturition Cycle
Normal desire
to void
First sensation
to void
Bladder filling
Bladder filling
Detrusor muscle
relaxes +
Urethral
Sphincter
tone
Pelvic floor
Detrusor muscle
relaxed +
Urethral
Sphincter
contracts
Pelvic floor
Detrusor muscle
contracts +
Urethral
Sphincter
Relaxes
(Voluntary control)
Pelvic floor
MICTURITION
Detrusor muscle
relaxes +
Urethral
Sphincter
tone
Pelvic floor

10. Bladder function: storage & voiding
ml maximum bladder capacity (less with aging)
first desire to void at 300 ml
“normal” voiding frequency 4-8 times per day and once at night

11. CNS control of bladder:

12. CNS control of bladder functioning:
Cortical Centre
frontal lobes are key to controlling the bladder by inhibiting detrusor (bladder muscle) contractions and their connection to the sacral roots via the SC is critical

13. CNS control of bladder functioning:
Pontine centre
receives input from the cerebral cortex
coordinates detrusor contraction and urethral relaxation
inhibitory impulses from the pontine centre allows bladder to store urine

14. CNS control of bladder functioning:
Sacral Centre
mechanism that mediates voiding in infants and in adults following SCI above the lumbosacral spinal segments

16. Types of incontinence anyone can experience:
Stress
urge
overflow
functional

17. Stress incontinence: Not related to CVA - most common UI in women
sudden increase in intra-abdominal pressure (laugh, cough, exercise)
related to weak pelvic floor muscles, loss of estrogen, positioning of bladder or urethra
Can occur in men post radical prostatectomy

20. Urge incontinence:
Loss of urine with a strong unstoppable urge to urinate
S&S: frequency day & night, UI on way to bathroom, small voided volumes, common in men & women
Common in neurological injury/condition e.g. CVA
Also known as “overactive bladder”

21. Overflow Incontinence:
Bladder full at all times & leaks any time
related to partial obstruction of bladder neck (e.g. enlarged prostate, pelvic prolapse in women), secondary to medication, fecal impaction, diabetes or lower SCI
S&S: dribbling, urgency, frequency, hesitancy

22. Functional Incontinence:
UI that results from barriers that prevent the person from getting to the BR in time
e.g. impaired cognitive functioning (Alzheimer’s), or impaired physical functioning (arthritis)

23. Stroke & UI: depends on part of brain affected

24. How strokes affect UI: FRONTAL STROKE
voluntary control of the external sphincter but uninhibited bladder contraction
strong urge to void with short/no warning
persistent frequency, nocturia, urge incontinence

25. Parietal & Basal Ganglion Stroke:
Uninhibited bladder contraction
voiding is obstructed as the bladder and urethral sphincter contract at the same time
may lead to ureter reflux and renal damage
overflow incontinence

26. Hemispheric Stroke:
Secondary to immobility and dependency on others rather than direct effects from the stroke

27. Additional risk factors for UI:
Urinary tract infections
caffeine intake
low fluid intake
constipation
weak pelvic floor muscles
mobility impairment
cognitive impairment
environmental barriers
medications e.g. diuretics, sedatives

28. Assessment of Urinary Incontinence
Incontinence history
Fluid intake
Bowels
Medical history
Medications
Functional ability
Voiding record

29. Incontinence History Onset Duration Daytime/nighttime Accidents
Stress loss
Urge loss
Aware of loss?

30. Fluid intake
How much
Restrictions
Caffeine
alcohol

31. bowels
Pattern
Constipation
Diet
Laxatives

32. Medical history: Stroke Parkinson’s Multiple Sclerosis Diabetes
Repeated urinary tract infections
Acquired brain injury
Dementia

33. medications Diuretics Anticholinergics Estrogen Sedatives/hypnotics
Antidepressants

34. Functional ability Access to bathroom Ambulation wheelchair
Needs assistance
wheelchair

35. Impact of cognitive impairment on ability to be continent:
Ability to follow & understand prompts or cues
Ability to interact with others
Ability to complete self care tasks
Social awareness

36. Physical assessment: Post residual volume urine culture
vaginal examination
rectal examination
Voiding record:
time and amount of fluid intake, urine voided, incontinence x 3-4 days

37. Conservative treatment all team members can do:
Client/family focused
using education
behaviour modification
problem solving strategies

38. Fluid intake changes Reduce/eliminate caffeine intake
reduce/eliminate alcohol intake
ensure adequate fluid intake
( ml)
Temporarily reduce intake when going out (urgency)
Nothing to drink two hours prior to going to bed for the night

39. Pelvic muscle exercises (Kegel’s)
Strengthen pelvic floor muscles
helps with stress or urge UI
need more than verbal instruction
Tighten anal sphincter as if you do not want to pass rectal gas
hold contraction for count of 3 then relax for 3

41. Urge suppression strategies
pelvic floor exercises
urge suppression using distraction techniques
aim: gradually  voiding intervals & voiding volumes ( ml)
voiding/prompted voiding q 3 hours

42. Treatment Medications: Anticholinergics:
Reduce irritability of the bladder
larger bladder volumes
reduces frequency
Available in long acting dose
e.g. Oxybutinin(Ditropan), Tolterodine (Detrol),

43. Anticholinergics potential side effects: dry mouth drowsiness, fatigue
altered mentation with diminished ability for complex problem solving
hypertension, tachycardia
insomnia

44. Treatment Medications: Estrogen
Local estrogen cream, suppositories or estring helpful with atrophic vaginal changes
help with symptomatic complaints of dryness, UI, UTI

45. Toileting strategies: less severely cognitively impaired & more mobile benefit more
Timed voiding
Person is toileted on a schedule & voiding recorded on chart
Their schedule can be gradually adapted to match their individualized voiding schedule
Prompted voiding
person again toileted on regular schedule but is asked if they need assistance

46. Prompted voiding:
↓ number of incontinent episodes/day & ↑ number of continent voids
Can be used with people with physical or mental impairments
Identification of individual voiding patterns rather than routine toileting e.g. q2h can be more successful
Determine individual voiding pattern by voiding record

47. Vaginal pessaries
Worn intra-vaginally to support cystocele or uterine prolapse

48. Products Use pads made for urine loss pads for men
not menstrual pads, facecloths or tissue
pads for men
Night time briefs helpful during heavier wetting times
use unscented, mild soap sparingly

49. Referral to medical specialist (urologist, urogynecologist, gynecologist):
Significant post void residual
abnormal urine dipstick test
pelvic organ prolapse
constant dribbling
frequent UTI’s
No response to conservative treatment

50. Questions/Comments? Laura Robbs, Clinical Nurse Specialist-Continence
Trillium Health Centre
ext. 3267

51. References:
Coleman Gross, J. (2003). Urinary incontinence after stroke: Evaluation and behavioral treatment. Topics In Geriatric Rehabilitation. 19(1):
Harari, D., Norton, C., Lockwood, L., & Swift, C. (2004). Treatment of constipation and fecal incontinence in stoke patients: Randomized control trial. Stroke. 35(11):
Smith, T.L. (2008). Medical complications of stroke. Up To Date.