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

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

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)

Responses to UI: Fear embarrassment shame anxiety frustration guilt anger

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

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

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

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

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

Bladder function: storage & voiding 400-600 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

CNS control of bladder:

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

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

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

Types of incontinence anyone can experience: Stress urge overflow functional

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

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”

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

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)

Stroke & UI: depends on part of brain affected

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

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

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

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

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

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

Fluid intake How much Restrictions Caffeine alcohol

bowels Pattern Constipation Diet Laxatives

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

medications Diuretics Anticholinergics Estrogen Sedatives/hypnotics Antidepressants

Functional ability Access to bathroom Ambulation wheelchair Needs assistance wheelchair

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

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

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

Fluid intake changes Reduce/eliminate caffeine intake reduce/eliminate alcohol intake ensure adequate fluid intake (1500-2000 ml) Temporarily reduce intake when going out (urgency) Nothing to drink two hours prior to going to bed for the night

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

Urge suppression strategies pelvic floor exercises urge suppression using distraction techniques aim: gradually  voiding intervals & voiding volumes (300-400 ml) voiding/prompted voiding q 3 hours

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

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

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

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

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

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

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

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

Questions/Comments? Laura Robbs, Clinical Nurse Specialist-Continence Trillium Health Centre 905-848-7580 ext. 3267 lrobbs@thc.on.ca

References: Coleman Gross, J. (2003). Urinary incontinence after stroke: Evaluation and behavioral treatment. Topics In Geriatric Rehabilitation. 19(1): 60-84. Harari, D., Norton, C., Lockwood, L., & Swift, C. (2004). Treatment of constipation and fecal incontinence in stoke patients: Randomized control trial. Stroke. 35(11): 2529-2555. Smith, T.L. (2008). Medical complications of stroke. Up To Date. www.uptodate.com