A patient asks about treatment for stress urinary incontinence which is the nurses best response

Incontinence is rarely the reason a patient is admitted to hospital; however, it plays an important part in their recovery. Continence issues are often treatable and, in some cases, reversible.

Hospital admission presents an excellent opportunity to investigate continence issues and develop a management plan. This could improve the patient’s experience and recovery, and have lasting positive impact after discharge.

In addition to following health service policy and procedures, the following actions can help identify patients with continence issues and risks.

Screening questions

Continence is a sensitive issue. Even though we might talk about this topic with patients every day, we need to be mindful to:

• actively listen to the patient and avoid making judgements
• respect the patient’s right to choose the most appropriate treatment option.

While there are no validated screening tools available, when a person is admitted it is useful to establish their usual bowel and bladder habits. Ask these screening questions:

• Do you leak urine before you get to the toilet?
• Do you have to wear pads?
• Do you suffer from constipation or diarrhoea?
• Do your bowels or bladder ever cause you embarrassment, pain or concern?
• Are you rushing to the toilet or looking for the toilet all the time?
• Are you going to the toilet every half an hour? (in addition to leaking urine, overflow incontinence can also be identified by frequency)
• Was this an issue before you were ill or has it become worse?

If a patient answers YES to any of these questions, they should be assessed for incontinence.

If the person has a pre-existing cognitive impairment or is experiencing delirum, confirm their answers with their family or carer. If applicable, contact the patient’s residential care facility to obtain their continence plan. This information will help identify the risk of episodes of incontinence during their stay.

Assess contributing factors

As a first step, we should seek to eliminate as many contributing factors to incontinence as possible.

Use DIAPPERS to screen for reversible causes1:

• D elirium
• I nfection--urinary (symptomatic)
• A trophic urethritis and vaginitis
• P harmaceuticals
• P sychological disorders, especially depression
• E xcessive urine output (for example, from heart failure or hyperglycemia)
• R estricted mobility
• S tool impaction

Also ask about:

• decreased fluid intake
• urinary retention
• lack of toilet access
• whether the patient is emptying their bladder, especially if they have a neurological condition.

Use the Urinary Distress Inventory to check for symptoms of incontinence on admission.

Once you have identified an issue and treated underlying causes, further assessment may include physical examination, taking a brief targeted history, gathering more information on the person’s usual baseline functional abilities and using standardised tools to gather more evidence.

Take a history

A person may have a mixture of continence types, which can make the underlying cause more difficult to work out. Take a brief and targeted history, gathering the following information.

Bladder and bowel symptoms

• urge
• stress
• voiding difficulty - hesitancy, intermittency, weak stream, incomplete emptying
• blood in the urine (haematuria)
• waking at night to go to the toilet (nocturia)
• pain or difficulty urinating (dysuria)
• postmenopausal/prostatism

Exclude

• malaena
• rectal bleeding
• anaemia
• loss of weight
• unexplained change in bowel habits
• nocturnal diarrhoea
• abdominal or pelvic mass.

When the problem occurs

• >during the day or during the night

Women

• gynaecological/obstetric history (the most common cause of stress urinary incontinence in women is childbirth).

Men

• urologic history (the most common cause of stress urinary incontinence in men is benign prostatic hypertrophy).

Other medical conditions or chronic diseases

• arthritis and related disorders
• musculoskeletal conditions
• neurological conditions such as Parkinson’s Disease, Multiple Sclerosis
• stroke
• diabetes
• dementia.

Medications

• diuretics
• high blood pressure medications
• antidepressants and sedatives
• muscle relaxants and sleeping pills
• calcium channel blockers (can cause constipation)
• non-prescribed drugs.

Fluid and fibre intake

How they are managing

• mobility
• using toilet facilities
• continence aids
• the social and routine activities. Some people report a restriction on their ability to lead their lives2 and stigma about incontinence can be a barrier to seeking help.3

Examine relevant systems

If needed, check the following:

• Fluid status and signs of dehydration
• Abdominal examination and rectal and genital examination, looking for
  • palpable bladder
  • incontinence associated dermatitis
  • for women
    • signs of vaginal atrophy or prolapse
    • pelvic floor muscle contraction
  • for men
    • prostate shape, size and consistency
    • pelvic floor muscle strength.
• Cardiac and respiratory examinations:
  • cardiac failure history and treatment
  • obstructive sleep apnoea (can lead to nocturnal polyuria and nocturia)
• Neurological examination to include cognition and function/mobility.

Investigate the evidence

The following investigations can help us better understand urinary tract function, other conditions, patient management and the degree of continence to aim for (dependant, social, independent).

• Two-day bladder chart:
  • include voided volumes for two consecutive days and nights
  • note if incontinent and the degree of leakage (damp/wet/soaked).
• Urine full ward test (dipstick): refer the patient to medical staff if nitrite/leucocyte/blood positive.
• Bowel chart: Bristol Stool Chart©.
• Post-void residual scale: is collected using a bladder scanner
  • if < 100 mL - no action
  • if > 100 mL - refer to medical staff. Incomplete bladder emptying leads to urinary stasis and increases risk of UTI
  • if >500 mL – refer to medical staff as soon as practicable. This may imply urinary retention requiring catheterisation.
  • Note: When using the scanner select male or female setting; for female with hysterectomy, select male setting.
• Abdominal X-ray
  • May be recommended to rule out abdominal masses and can be useful in identifying faecal impaction.

1. Resnick, N.M. and S.V. Yalla, Management of Urinary Incontinence in the Elderly. The New England Journal of Medicine, 1985. 313: p. 800-804.

2. Mitteness, L.S. and J.C. Barker, Stigmatizing a normal condition: urinary incontinence in late life. Medical Anthropology Wuarterly, 1995. 9: p. 188-210.

3. Heintz, P.A., C.M. DeMucha, M.M. Deguzman, R. Softa, Stigmas and microagression experienced by older women with urinary incontinence: A literature review. Urologic Nursing, 2013. 33: p. 299305.

Making the decision to have surgery can be very personal. It is made in consultation with your surgeon based on the characteristics of your incontinence, your goals and your preferences.

It helps to learn as much as you can before you decide to move forward with surgery. Explain your goals to your healthcare provider. Find out which type of surgery is recommended and how much it may reduce urine leaks to see if it's worth doing. Learn what to expect during and after surgery. Also ask about risks and possible complications.

Here are a few sample questions for your healthcare provider to help you make the best decision:

• Which surgery is best for me? Why?
• What are the risks with surgery?
• Will surgery fix my SUI completely?
• How long is the recovery?
• Will I still have incontinence or other symptoms after surgery?
• Will my insurance pay for surgery?
• Should I do this now, or wait?

Waiting to have SUI surgery won't harm you. Unlike some other medical conditions, delaying SUI surgery doesn't usually change the outcome.

Surgery for SUI in women is usually very successful. While each of the most commonly performed surgeries are similar in terms of success rates, they have different risks. It is important to understand your options so you can feel confident about the decision you make. If you want to find out more about SUI surgery, ask your healthcare provider what kind may work best for you, why and for how long.

Below are different surgical procedures specific to men and women for SUI.

Urethral Injections for Women with SUI

Urethral Injections/Bulking Agents

Urethral injections are used to "bulk up" the urethral sphincter muscle that keeps the urethra closed. "Bulking agents" are injected into the urethra. This helps the sphincter to close the bladder better.

Often, the injections are done under local anesthesia in your healthcare provider's office. The injections can be repeated if needed. This method may not be as effective as other surgeries, but the recovery time is short. Bulking agents are a temporary treatment for SUI. Of every 10 women who have these injections, between 1 in 3 are cured of leaks, which can last for a year.

Sling Surgery for Women with SUI

The most common surgery for SUI in women is "sling" surgery. In this surgery, a small strip of material (a sling) is placed under your urethra to prevent it from moving downward during activities. It acts as a hammock to support the urethra. Many sling techniques and materials have been developed. Slings can be made from your own tissue, donor tissue or surgical mesh.

For any type of sling surgery, there are different risks that should be discussed with your surgeon before starting. These are the primary sling surgeries used to treat SUI:

• Midurethral sling-The midurethral sling is the most common type of surgery used to correct SUI. The sling is made out of a narrow strip of synthetic mesh that is placed under the urethra with a variety of techniques: retropubic, transobturator and single-incision. Your doctor will recommend which anchoring location is right for you and review risks.

  • For sling surgery made from surgical mesh, the surgeon may only need to make a small cut (incision) in the vagina. The sling is then inserted under the urethra and anchored in the surrounding pelvic floor tissue. This surgery is short and recovery may be shorter than with an autologous sling. There are additional risks associated with using mesh that you should discuss with your surgeon.

• Autologous sling-In this type of surgery, the sling is made from a strip of your own tissue (autologous) taken from the lower abdomen or thigh. The ends of the sling are stitched in place through an incision in the abdomen.
  

To use your own body tissue for a sling, an additional incision is made in the lower belly or in the thigh to collect tissue that will used for the sling. A specialist may be needed to provide this option (it's not as common as mid-urethral synthetic sling surgery). Autologous sling surgery is usually done through a cut in the bikini line. Or it can be done making a cut over the thigh. The surgery is most often done in less than 2 hours. This surgery does require more time to recover than a mid-urethral sling surgery. There are additional risks associated with this type of surgery. Talk with your surgeon about them.

Bladder Neck Suspension

Bladder Neck Suspension is also called Retropubic Suspension, Colposuspension or Burch Suspension.

In this surgery, sutures are placed in the tissue along the side of the bladder neck and urethra and attached to a ligament along the pubic bone. This supports the urethra and sphincter muscles to prevent them from moving downward and accidentally opening. There are certain risks with this surgery, as with all surgery, that should be discussed before making your decision. The surgery can be done open or laparoscopically under general anesthesia in less than a few hours. it requires more time to recover than mid-urethral sling surgery.

Surgery for Men with SUI

There are surgical options specifically for men with SUI. Talk with your healthcare provider to find out which treatments may work for you.

Artificial Sphincter

The most effective treatment for male SUI is to implant an artificial urinary sphincter device. This device has three parts:

1. A fluid-filled cuff (the artificial sphincter), surgically placed around your urethra.
2. A fluid-filled, pressure-regulating balloon, inserted into your belly.
3. A pump you control inserted into your scrotum.

The artificial urinary sphincter cuff is filled with fluid which keeps the urethra closed and prevents leaks. When you press on the pump, the fluid in the cuff is transferred to the balloon reservoir. This opens your urethra and you can urinate. Once urination is complete, the balloon reservoir automatically refills the urethral cuff in 1-3 minutes.

Artificial sphincter surgery can cure or greatly improve urinary control in more than 7 out of 10 men with SUI. Results may vary in men who have had radiation treatment. They also vary in men with other bladder conditions or who have scar tissue in the urethra.

Male Sling for SUI

Similar to female mid-urethral slings, the male sling is a narrow strap made of synthetic mesh that is placed under the urethra. It acts as a hammock to lift and support the urethra and sphincter muscles. Most commonly, slings for men are made of surgical mesh. The surgical incision to place the sling is between the scrotum and rectum.

The male sling is most often used in men with mild to moderate SUI. It is less effective in men who have had radiation therapy to the prostate or urethra, or men with severe incontinence.