1. Managing Urinary Incontinence
Facilitator
Guide
Catherine Van Son, Ph.D., R.N.

2. “ A journey of a thousand miles begins with one step.”
(or one drop) Lao-tse
Learning Objectives:
to describe UI and the impact the condition can have
on the individual and society
to differentiate the differences between the various
kinds of UI, assessments, and treatments
to state methods to minimize the impact of
chronic incontinence
There is no one single intervention for managing urinary incontinence.
Management involves several steps that can lead to the reduction or
elimination of incontinence.

3. Urinary Incontinence
Defined as an involuntary loss of urine in sufficient amount or frequency to cause social and/or health problem
Is not a normal consequence of...
- aging
- menopause
- pregnancies
(although physiological changes such as those listed may contribute to the development of incontinence)
These conditions may contribute to episodes of UI,
but UI is not an automatic consequence of these conditions.
Other contributing factors:
weight gain
pelvic surgery
prostatectomy
lowered estrogen levels in menopause
post childbirth (related to trauma to the pudendal nerve which innervates the pelvic musculature)

4. UI is not reported because of...
embarrassment
lack of information
a belief it is part of aging
health care providers don’t ask
a belief there is no effective treatment
fear of the therapies used to manage the problem
Ask participants to discuss other reasons why UI is not
addressed by:
health care providers
family members
individuals with UI

5. Psycho-social Impact loss of self esteem embarrassment
decrease in ability to maintain independence
social isolation
depression
anxiety
poor quality of life
risk of institutionalization
should not underestimate the psychological impact of UI
should suspect UI as a possible cause when we see some of
these behaviors
in a study of cognitively intact homebound elders, those with UI perceived it as a problem that further restricted their activities. Subjects had a mean age of 75.8 years, a mean of 8.4 medical problems, and most 80%, had functional limitations in ambulation.
--54% reported that UI further restricted their activities
--52% reported that this problem was extremely disturbing.
--90% believed that it could be treated. (JAGS Vol. 44 No.8 August 1996.)
Handout: Family member with UI

6. Self-care behaviors used:
locates or stays near a bathroom when out
voids more frequently
wears protective garment
restricts fluid intake
does not take certain meds if going out
restricts social / physical activity
Only one in 12 women with UI seeks diagnosis and treatment.

7. What is normal? daytime: nighttime:
frequency of no more than once every 2 hours
nighttime:
1-2 voidings are considered normal
Daytime: every 2 hours, should be able to sit
through a movie
Nighttime: greater than twice a night is called Nocturia.
This is extremely disruptive, with consequences
such a falling when getting up at night to go to the bathroom,
and sleep deprivation causing fatigue, forgetfulness,
disorientation, and depression.

8. Age Related Changes
decreased bladder capacity (normal is ml., older adult capacity may be 250 ml.)
increased residual urine
increased involuntary bladder contractions
decreased outlet resistance (females)
decreased ability to inhibit contractions
increased outlet resistance (males)
In General:
Bladder capacity: From ml to about 250 ml in older age
Kidneys: decrease in size about 20 to 40% between ages of 40-90
less efficient at concentrating urine, causing an increase in urine volume
Muscular structures: lose tone and elasticity such as the detrusor muscle resulting in incomplete bladder emptying
decrease in the ability to postpone urination decrease in urethral closing pressure
increase in spontaneous detrusor muscle contractions

9. Forces that Affect the Pelvic Floor
Anatomical
Neurological
Why would the female
anatomy increase incidence
of urinary incontinence?
In which ways do the
nerves affect the pelvic
floor?
Pelvic Floor
Hormonal
How does estrogen
affect the pelvic floor?
Neurological: nerves that support musculature and organ function
Mechanical: pressures from pregnancy, constipation and or prostate enlargement
Anatomical: position of bladder, length of urethra
Hormonal: role of estrogen
Psychological: beliefs about UI and treatments
Mechanical
What is the impact of
pregnancy, constipation,
and/ or prostate enlargement ?
Psychological
How would one’s psychological
status impact incontinence?

10. Risk factors for UI immobility/chronic degenerative disease
impaired cognition
medications
obesity
diuretics
fecal impaction, constipation
low fluid intake
environmental barriers
diabetes
stroke
estrogen depletion
smoking
Most of these factors can be managed and the impact on UI decreased.
Additional risk factors:
Immobility:
Pain
ambulation to BR difficult
( i.e. rheumatoid arthritis)
Vision changes
Each of these factors can increase one’s
risk for experiencing urinary incontinence.
Often older adults experience more than one risk
factor at any given time.

11. Medications can cause... frequency urgency retention fecal impaction
polyuria
nocturia
immobility
sedation
delirium
Handout: Medications and UI

12. Incontinence History Medical History? Frequency? Sensations?
Medications?
Amount?
Obtaining a history can be time consuming but is the most valuable part of the assessment / treatment process.
Medical History: Diabetes
CVA
Parkinson’s
Dementia
Frequency: hourly, daily, weekly
Amount: dribbles, small wet spot, soaked clothes
Sensations: urgency, dysuria, no warning
Medications: See medication handout

13. Incontinence Screening “DRIP”
NOTE: Any one of these conditions can cause acute onset urinary incontinence and must be evaluated promptly !
D - delirium, depression
R - retention, restricted mobility
and/or environment
I - infection, inflammation,
impaction
P - pharmaceuticals, polyuria, pain
Causes of acute and reversible forms of urinary incontinence
D- depression: may not feel like going to the BR
delirium, dementia: may not know what to do in the BR
R- retention: based on enlarged prostrate, or medications
restricted mobility: restraints, needs CG assistance
I- infections: UTI’s, urethritis, vaginitis
impaction: fecal
P- pharmaceuticals (see medication Handout)
polyuria: diabetes, nocturia

14. Kinds of Urinary Incontinence
Stress
Functional
Environmental
Urge
Overflow
Iatrogenic (caused by hospitalization, medications, etc.)
Mixed
In addition there is...
Mixed Incontinence - a combination of stress and urge
Iatrogenic Incontinence -caused primarily by
medications

15. Stress Incontinence
loss of urine that occurs during activities that increase intra-abdominal pressure:
coughing
sneezing
laughing
physical activity (lifting heavy objects)
caused by pelvic muscular weakness as a result of
pregnancy
obesity
surgery
medications
aging (lower estrogen levels)
Stress UI is the most common form of UI and the most treatable.
Other potential indicators:
getting up from a chair or out of bed
when walking or other exercise
frequent trips to the BR to avoid accidents

16. Pelvic Floor Muscle Exercises
Intervention for stress incontinence
Also known as Kegel exercises
Requires 2-5 sets of pelvic muscle contractions done several times each day
Feedback needed so client knows they are doing them correctly, such as...
vaginal palpation
biofeedback
vaginal cones (Look this up; what are they and how are they used?)
Like all exercises; success depends on doing them regularly.
Other recipes:
5 minutes 2 times a day
If prostate surgery is scheduled, pelvic muscles should be checked for strength (by same clinics that treat UI)

17. Functional Incontinence
physical or psychological impairment that results in incontinence when the urinary tract is healthy
causes:
Decreased mobility
Pain
Clothing
Psychological factors
Focus on the individual’s ability to toilet him/herself
Lack of toilet or toilet substitute
Restraints
Improper footwear, (fear of falling)
Dressing / undressing issues (privacy)
Medications causing polyuria / sedation
Mobility issues: CVA, amputation
Depression, Delirium, Dementia
Pain (arthritis)
May not remember what to do in the BR
Task may be too complicated
Doesn’t know when s/he needs to urinate
How might these issues cause incontinence
when the urinary tract is healthy?

18. Functional Assessment
ability to put on /take off clothing
sequence of tasks involved with toileting
mobility: ability to ambulate, use a w/c and/ or transfer to and from the toilet
access to toilet /device (such as urinals, bedside commodes, etc.)
Simplify clothing: using velcro or elastic instead of buttons or zippers
Encourage the use of undergarments whenever possible, gives the message to try to stay dry and use the toilet when wet. (See padded underwear in catalogs)
Change clothes when wet, ASAP, so client doesn’t get accustomed to wet clothes
Use easy to wash clothing and shoes (tennis shoes are easy to wash and provide a none slip surface to prevent falls on wet floors)
Resources: Adaptive clothing catalogs (ex.Buck & Buck)
Adaptive equipment
OT evaluation
catalogs
See Learning activity:

19. Environmental Incontinence
psychological message that UI is expected
chairs are plastic
beds are protected
pads are available and applied “just in case”
architectural design
long corridors
poorly marked bathroom doors
caregiver attitudes
“Go ahead and go (urinate), I’ll clean you up later.”
“S/he does that on purpose.” (Episodes of incontinence)
delay in removing wet clothing
Definition: UI due to external barriers such as equipment, signs, building design and caregivers
Signs can be a problem: see example
Distances too far
Floor & toilet same color making it hard to find the toilet
Lack of privacy
Poor lighting
Clutter : pets, tubing, newspapers
Bed may be too high, chairs too high & deep: difficult to get out
TV ads for incontinent products assume that UI is a natural consequence of aging

20. Environmental Assessment
location/ accessibility of toilets
signs for bathroom
call lights/ bells
adaptive equipment
cleanliness, safety
“try a bright awning over BR door so it can be seen
from a distance” (Robinson,A. et al,1996)
paint BR doors a different color
use signs in large print that say “Bathroom” &/or a
picture of a toilet (Robinson,A. et al,1996)
grab bars (placed in the BR and on the bed)
keep BR floor dry to prevent falls
adaptive equipment
urinals / commodes
raised toilet seats

21. A true story… Once there was a gentleman with mild
cognitive impairment who was able to
toilet independently. However, since
coming to this new adult day center he
has been voiding in flower pots and trash
cans, and wandering into apartments
next to the adult day center to use
the bathrooms of tenants who live
there, which they are not happy
about.
What should be done? Think about the
environment.

22. Bathroom Signs
What was puzzling is that he passed by four bathrooms that were designated for the
participants in the adult day center.
Upon further investigation, it was discovered
that the day center bathroom doors were always
closed due to fire regulations and the signs by
the bathrooms were like the one here on the right.
Could a person with mild dementia understand that
this sign was for the bathroom?
Typical signs found now outside public restrooms,
however not well recognized by cognitively impaired.
Make signs with actual pictures of toilet and use words like toilet & bathroom

23. Solution
Since he could not tell us we had to make an educated guess.
We enlarged a picture of a toilet, similar to this one and taped it to each of the day center bathroom doors.
What do you think happened?
(You are correct if you think that he gave up the flower pots for the toilet. The universal sign for bathrooms may be a barrier to cognitively impaired individuals.)
Toilet

24. Urge Incontinence is…
a loss of urine with an abrupt and strong desire to void.
“I’m unable to make it to the bathroom on time.”
caused by an overactive detrusor muscle, resulting in excessive involuntary bladder contractions that may be initiated by:
cancer (bladder / prostate)
infection
spinal or nerve damage
often found in individuals with
diabetes, stroke, dementia, Parkinson’s disease, or
multiple sclerosis
Leakage of urine (usually larger in volume than stress incontinence) because of inability to delay voiding after sensation of bladder fullness is perceived.
When they hear or touch running water, open the garage door, put the key in the lock.
Detrusor motor &/or sensory instability, isolated or associated with one or more of the following:
Local genitourinary condition:
cystitis, urethritis, tumors, stones, diverticuli,
and outflow obstruction
CNS disorders:
stroke, dementia, parkinsonism, spinal cord injury or disease

25. Urge Incontinence: Treatment
Behavioral therapy
bladder training
Electrical Stimulation
biofeedback
Medications
Biofeedback
works best with clients in which physiological processes are relevant (Futterman & Shapiro,1986)
muscle tension (emg feedback)
skin temperature (thermal feedback)
brain waves (EEG feedback)
respiration

26. Bladder Retraining treats urge incontinence voiding by the clock
“Freeze & Squeeze” OR
“Sigh and be Dry”
(these actions can help clients get through initial sensations to void that occur more frequently with this kind of incontinence. Not voiding with each urge can retrain the bladder, so that the need to void is increased to every two hours and/or when bladder is actually full.)
treats urge incontinence
voiding by the clock
times set by voiding diary
gradually inc voiding interval to 3-4 hours
lengthen time pattern with improvement
(usually in 15 min. increments, weekly)
“Freeze & Squeeze” OR
“Sigh and be Dry”
until urge passes

27. Overflow Incontinence
loss of urine related to the overdistention of the bladder
frequent or constant dribbling
may include urge or stress UI
causes
loss of bladder muscle tone and/or outlet obstruction
MS, DM, outflow obstruction (BPH), spinal or nerve damage
least common, hard to diagnose
treatment
review medications
drainage: intermittent, continuous
Leakage of urine (usually small amounts) resulting from mechanical forces on an overdistended bladder or from other effects of urinary retention on bladder & sphincter function
Lose small amounts during day and night
Get up often during the night to go to the BR
Often feel as if you have to empty your bladder but can’t
Pass only a small amount of urine but feel as if your bladder is still partly full
Spend a long time at the toilet, but produce only a weak, dribbling stream of urine.
Treatment: relief/removal of obstruction, intermittent catheterization program (ICP), medications, Crede, Foley Catheter

28. When to Refer? marked pelvic prolapse marked prostate enlargement
difficulty passing a 14 Fr. catheter
most cases of overflow
hematuria
treatment failures
Some causes of UI need further evaluation by a urologist or surgeon. After conservative measure are attempted referrals are often helpful in determining if other measures may be indicated.

29. Treatment Options for UI
behavioral techniques
biofeedback
scheduled toileting
exercise
medication
surgery
continence promoting devices
Pessary (read your textbook or search the internet to find out how these help women with incontinence)
Potential fixable causes of UI available per MDS were:
Medications- antipsychotics, antidepressants, antianxiety hypnotics
Congestive Heart Failure, DM, Pedal Edema,Delirium, Depression,
Impairments in ADL’s (transfers, ambulation, dressing, toileting, bedrails, restraints)
Continence Promotion Devices: Pessary
Surgery to suspend bladder post-prostatectomy to avoid the shift of the bladder downward to fill the 2-4cm space left thus causing UI
1 in 4 men suffer UI post prostate surgery
Medications: to reduce excessive detrusor muscle contractions (antispasmodics)
to stimulate detrusor muscle contractions
to regulate detrusor muscle instability (urge UI, anticholinergics, can cause smooth muscle relaxation)
“Men don’t assume it’s their fate, so they are more likely to go to a physician. Women are more likely to just go buy some Depends” But in about 80% of cases, treatment could help women.

30. Management of UI is a team effort
Must involve:
the client
family
caregiver(s)
nursing
primary care provider
dietician
PT/OT/RT/SLP
management
Each member of the team has a perspective on the uses, causes and solutions:
Client: History of problem, how they have dealt with it
Family: History, what have they observed
Caregiver(s): What has/has not worked?
PCP: Assessments, identify causes, treatments
Nursing: voiding record, plan, products
PT: client mobility
OT: toileting, dressing skills and devices
RT: activity program to inc mobility
SLP: communication issues
Dietician: food & fluid issues
Management: supply and personnel resources

31. Behavioral Interventions
are non-invasive
involve caregiver and individual
measure outcomes
are inexpensive
are effective
are low risk
Behavioral vs. Drug Treatment for Urge Urinary Incontinence
in Older Women, Burgio,K. et al. Vol.280, pp ,
Dec 16,1998
Results:
Behavioral treatment (biofeedback) yielded a reduction of 80.7% UI
Drug Treatment (oxybutynin) 68.5 % reduction
Placebo control 39.4%
Clients perceived improvement was greatest with behavioral
treatment (74.1%) “much better” vs. 50.9% and 26.8 % for
drug treatment and placebo
Only 14% of the behavioral group wanted to try other treatments,
75% of the other groups wanted to try behavioral approaches.

32. Unlocking UI: Behavioral Methods
assessments
food and fluid changes
pelvic floor muscle exercises
bladder retraining
education
Refer to assessment form and be sure to assess
functional
environmental
caregiver
aspects of UI.

33. Bladder (Voiding) Record
time voiding occurs
type/ amount of incontinence
presence of urge sensation
activity associated with loss of urine
daily number of pad changes
intake of dietary irritants
fluid intake
See examples of various forms that can be used to obtain
this information for analysis.
time voiding occurs
type / amount of incontinence
large amount - urge
small amount- stress
presence of urge sensation
activity associated with loss of urine
daily # of pad changes
intake of dietary irritants
fluid intake

34. Example of Voiding Record
Refer to various voiding record handouts for examples.

35. Physical Exam Abdominal/Pelvic/Genitalia/Rectal exam
Neurological Status
Dexterity
Mental Status
Mobility
See Short Portable Mini-Mental Status Exam
3 minute recall
DLROW
clock drawing
See Geriatric Depression Scale
See Get up & Go test ( for mobility screening)
Examination for:
Abdominal masses, bowel tones, prolapses,
infections, impactions etc.

36. Maintain/Promote Mobility
assessments by OT / PT / SLP
use of assistive devices
walkers, canes
exercise programs
proper shoes
foot care
uncluttered walkways
Mobility is crucial to the reduction / management of UI.
The more mobile and agile an individual is the longer continence can be maintained and and level of dependence on caregivers minimized.

37. Absorbent Products trial and error evaluate products for...
skin irritation
noise
comfort
odor control
ease of use/ability to change
absorption
confidence
There is improved success in selection after
a thorough assessment
Note: with dementia clients
remember they often don’t understand
what paper products are for; frequently
refusing them or ripping them off
Try reusable incontinent products

38. Factors to consider with absorbent products
skin integrity
comorbidity
optimal product for client
incidence of vaginitis/ bacteriuria
functional disability of client
type and severity of UI
gender
availability of caregivers
previous treatment programs
client preference
Show & Tell of various types of absorbent products.

39. Mild to Moderate UI Serenity (UI pad)
in one study received highest overall performance score
Always (menstrual pad)
Study found that menstrual products
were = to or better than UI products
and less expensive
(except for Serenity)
Refer to Handout on supply catalogs for product information.

40. Chronic Incontinence scheduled toileting improved access to toilets
fluid and diet management
absorbent garments/ devices
change clothes when wet
Absorbent products:
Use least expensive, least bulky, most normal
product that facilitates independence and dignity and
is the easiest for the individual and caregiver
Paper products are expensive
Try washable products first

41. Food & Fluids aim for 1500-2000 ml/day avoid bladder irritants
include jello, soups, popsicles, water-packed fruits etc. (caution with diabetics)
avoid bladder irritants
such as caffeine and chocolate
avoid evening fluids
treat dependent edema
elevation during the day
compression stockings
decrease sodium intake
Aim for ml/day
this approximately 6-8 (8oz.) total intake
Avoid bladder irritants
caffeine ( pop, coffee, tea, chocolate)
foods that acidify urine (citrus, carbonated beverages)
Avoid evening fluids
promotes nocturia
Treat dependent edema
Congestive Heart Failure (CHF)
elevate legs during the day
utilize compression stockings

42. Frequent UTI’s Cranberry juice, 10 oz daily Check fluid intake
must have at least 25% cranberry juice
Check fluid intake
Check post-void residual
Change catheter or remove
Cranberry juice:
does not aggravate UI
does not acidify urine
highly concentrated acids in cranberries prevent the
E.coli bacteria from attaching to the bladder lining
can cut UTI’s in 1/2

43. Dementia can double the incidence of UI
inability to dress and/or transfer can increase incidence 13 times
one study: 55% of ambulatory dementia clients became dry or had a significant improvement in UI with an individualized scheduled toileting program (Shelly, J. & Flint, A. (1995). Urinary incontinence associated with dementia. Journal of the American Geriatric Society, 43(2), 286.)
Dementia can have a significant impact on an individuals
ability to maintain continence. However, with caregiver
support continence is possible.

44. UI and Dementia: utilize habit voiding
dress in clothing that is easy to remove
stay with the client and do not distract
try again in 5 minutes if they say,”I just went.”
use language that is understood
simplify steps involved
keep bathroom warm and comfortable
Simplify steps: for example, “ Sit down”, perhaps adding a
gentle downward touch on the shoulder or a gentle touch
behind the knee to give tactile cues to sit down
Watch for non-verbal cues: reaching for their belt, tugging
at a zipper or taking pants down, and restless behaviors,
wandering, agitation
Use familiar language: some individuals respond to words used
in their past such as;“pee”, “tinkle”, or “take a leak”
Listen carefully: the person may use the wrong words, for example
“I want tea”, or “take a peek”.
No reprimands for accidents, be encouraging, reassure
(Robinson,A. et al,1996)

45. Habit Training voiding at predetermined times
goal: to decrease/eliminate number of incontinent episodes (keep dry)
fixed time intervals
allows for schedule adjustments
requires commitment
Predetermined times are based on the 3 day voiding diary
Fixed time intervals examples:
every 2-4 hours
individualized
related to events (usually mealtimes, get up in
am and going to bed)

46. Caregiver assessment Availability of caregivers?
Caregivers have the knowledge they need to manage urinary incontinence? (Schedules, safe transfers, signs/symptoms of UTI)
Are caregivers willing to help with continence?
Do caregivers have the equipment they need? (such as a gait belt for safe transfers)
Availability?
enough staff
organized
Knowledge?
know how to complete voiding log
what to report to supervisors
skills to encourage continence
ongoing training/ education
Willingness?
tries to follow the plan
encourage the client
Equipment?
products, assistive devices, gait belts
available

47. Caregiver frustration
educate
give lots of positive reinforcement
seek their input
problem-solve on weekly basis
start with one client at a time
tap into their creativity
Caregivers are often the key to success in any program
to eliminate / reduce UI in the older person.
Because continence is a hourly, daily issue, continual
monitoring, and support is needed to demonstrate the value
of continence promoting activities.

48. To ponder... The bladder is the mirror of the soul. Chinese proverb
The meaning of this proverb is up to the individual.
But when you really have to go, matters of the soul
can become unimportant.
When you gotta go
nothing else
really matters!

49. Urinary Incontinence was prepared by Catherine Van Son, Ph. D, R. N
Urinary Incontinence was prepared by Catherine Van Son, Ph.D, R.N. for the Older Adult Focus Project, OHSU School of Nursing.