Contrary to the belief of many older adults and even some health care providers, aging is not the sole cause of UI. However, aging does affect the lower urinary tract (Fig. 28–1). These age-related changes increase an older adult’s susceptibility to other insults to the lower urinary tract. As a result, these insults (e.g., drug side effects, UTIs, and conditions impairing mobility) are more likely to produce incontinence in older clients than in younger ones.

FIG 28–1 Male bladder. (From Lewis SM, Heitkemper MM, Dirksen S, O’Brien B: *Medical-surgical nursing: assessment and management of clinical problems*, ed 7, St Louis, 2007, Mosby.)

With age, bladder capacity decreases, the prevalence of involuntary bladder contractions increases, and more urine is produced at night. The reduction in bladder capacity and increased involuntary bladder contractions can lead to urgency and frequency. Many older adults find that they have to empty their bladders more often than they did when they were younger. Increased urine formation at night leads to nocturia. Nocturia occurs frequently in the older adult and is a major contributor to disruption in normal sleep patterns.

Changes occur in the urethra because of the aging process and because of decreased levels of estrogen after menopause. Thinning and increased friability of the urethral mucosa can contribute to urgency and frequency. A decrease in muscle tone and bulk can decrease urethral resistance. In addition to the changes in the urethra, declining estrogen levels affect pelvic floor muscle tone and function.

Although it is not considered a normal change associated with aging, as men get older the prevalence of prostatic hypertrophy increases. Enlargement of the prostate can interfere with bladder emptying and can also precipitate involuntary bladder contractions.

Prevalence of Urinary Incontinence

UI is very common in the older adult, especially among older women and is underrecognized (Halter et al, 2009). UI is even more common among nursing facility residents. Affecting slightly more than half of all nursing facility residents, UI is an independent predictor for nursing facility admission and is associated with irritant dermatitis, pressure ulcers, falls, significant sleep interruptions, and UTIs (Halter et al, 2009).

Myths and Attitudes

Despite the significant number of older adults with UI, most do not report the condition or seek medical treatment. This may be because they are embarrassed, believe it is not important enough to mention, or believe it cannot be treated. Research studies have indicated that common beliefs about UI may lead older clients, particularly older women, to think that incontinence is normal and not worth reporting to health care providers.

Many health care providers do not ask clients about incontinence. Even when clients inform them about incontinence, many providers ignore the problem and do not provide adequate diagnosis and treatment. Screening for urinary incontinence has increasingly become recognized as an indicator of quality of care (Halter et al, 2009)

Common Problems and Conditions

Acute Incontinence

UI is generally classified as either acute (transient) or chronic (persistent). Acute incontinence has a sudden onset, is generally associated with some medical or surgical condition, and generally resolves when the underlying cause is corrected (Ouslander, 2003) (Box 28–1). Medication is a common cause and should always be suspected as a potential cause of new incontinence. Although the exact prevalence of acute incontinence is not known, any new onset of incontinence should be considered acute, and possible precipitating causes should be ruled out. Addressing the cause has the potential to resolve the incontinence.

BOX 28–1 CAUSES OF ACUTE URINARY INCONTINENCE

• Poorly controlled diabetes mellitus

• Beta-adrenergic medications

• Alpha-adrenergic blockers

• Alpha-adrenergic agonists

• Calcium channel blockers

• Diuretics

• Psychotropics

• Narcotics

Chronic Incontinence

Persistent incontinence is not related to an acute illness. It continues over time, often becoming worse. Major types of persistent incontinence include stress, urge, overflow, and functional incontinence (Agency for Health Care Policy and Research [AHCPR], 1996; Dash et al, 2004). These types of incontinence can occur in combination, causing mixed incontinence.

Stress Incontinence

Stress incontinence is commonly seen in older women, who involuntarily lose urine as the result of a sudden increase in intraabdominal pressure. Stress incontinence occurs as pressure in the bladder (intravesical pressure) exceeds urethral resistance when intraabdominal pressure increases in the absence of a detrusor (bladder) contraction. This can be caused by a lack of estrogen, obesity, previous vaginal deliveries, and/or surgeries (Halter et al, 2009). Individuals with stress incontinence often leak urine with physical exertion such as coughing, sneezing, laughing, lifting, and exercise. Older women may report leakage when they change position (e.g., get out of a chair) or lift a small child. These activities increase intraabdominal pressure, which increases bladder pressure. If the urethra, supporting tissues, and bladder neck are abnormal, urethral resistance may be too low to withstand the increased pressure on the bladder, which results in involuntary urine loss. Stress incontinence is unusual in men, and it mainly occurs after transurethral surgery for benign conditions or after surgery or radiation therapy for lower urinary tract malignancy when the anatomic sphincters are damaged (Halter et al, 2009).

Urge Incontinence

Urge incontinence is also common in the older adult population. Urge incontinence is usually, although not always, associated with abnormal detrusor contractions (AHCPR, 1996; Dash et al, 2004). Common causes of urge incontinence include local genitourinary conditions such as cystitis, urethritis, tumors, stones, and diverticula, as well as central nervous system disorders such as stroke, dementia, and Parkinson’s disease (Ouslander, 2003). Individuals with urge incontinence typically give a history of involuntary urine loss after a sudden urge to void. Urgency and involuntary urine loss can be precipitated by the sound of running water, cold weather, or the sight of a toilet. Urinary accidents are sometimes large. Urge incontinence is often accompanied by nocturia and complaints of frequency. Urge incontinence can be classified as one of the following types, based on etiology and the bladder abnormality (AHCPR, 1996):

1. Detrusor hyperreflexia (DH), when the uninhibited bladder (detrusor) contractions are caused by a neurologic problem (e.g., stroke).

2. Detrusor instability (DI), when there is no underlying neurologic problem.

3. Detrusor sphincter dyssynergia (DSD), when the uninhibited bladder contraction is accompanied by contraction of the external sphincter. This results in urinary retention and may be seen in clients with suprasacral spinal cord lesions and multiple sclerosis.

4. Detrusor hyperactivity with impaired bladder contractility (DHIC), when uninhibited bladder contractions are accompanied by impaired contractility during voluntary voiding. As a result, the client must strain to empty his or her bladder either completely or incompletely. This type of urge incontinence may be seen in frail older adults.

Nursing Management

Assessment

The purpose of the nursing assessment for UI is to determine the type of incontinence and the factors contributing to it so that appropriate nursing interventions can be planned and implemented. In addition, the nursing assessment allows the nurse to identify those clients who need to be referred to a physician or nurse practitioner for a more complete evaluation. The assessment consists of a history assessment, functional assessment, environmental assessment, psychosocial assessment, physical examination, tests of provocation, and evaluation of bladder habits.

History

During the history assessment, information is collected about the client’s incontinence symptoms and bladder habits, general health and functional status, medical problems, current medications, and past medical, surgical, and obstetric history. If clients are able to provide the history, they are the most accurate source of data. In situations in which a client has cognitive impairment, however, the nurse may have to rely on secondary sources such as family caregivers or medical records.

During the incontinence history assessment, the following information should be collected:

• The onset of the incontinence

• The frequency and volume of accidents

• The circumstances that cause urine loss, including (1) any leaking of urine when the client coughs, sneezes, laughs, changes positions, climbs steps, exercises, has an urge to void, hears running water, is cold, or is sleeping, (2) any involuntary urine loss caused by caffeine, alcohol, or any medication, and (3) whether the client leaks urine without being aware that it occurred, has any postvoid dribbling, or leaks continuously

• Bladder habits, including the frequency and volume of daytime and nighttime urination

• Daily fluid intake, including caffeine intake

• Self-management techniques the client uses to manage the incontinence (e.g., frequent voiding, restricting the volume or type of fluid, incontinence products, urine collection devices)

• Previous evaluation and treatment of the incontinence, including the client’s perception of the effectiveness of previous treatment measures

• Any other urinary tract symptoms, including urgency, burning, pain, hematuria, weakness of the urinary stream, intermittent stream, and difficulty emptying the bladder completely

• Bowel habits, including constipation, laxative use, and fecal incontinence

In addition to the incontinence history, the nurse should also obtain a general health history. The nurse should inquire about current medical problems and specifically ask about problems that can affect bladder function (e.g., diabetes mellitus, congestive heart failure, bladder and kidney infections, strokes, Parkinson’s disease, depression, memory problems, mobility problems, problems with coordination, and other neurologic problems or injuries). The nurse should ask about current medications and treatments, including the use of over-the-counter medications. The nurse should inquire about previous surgeries, including past urologic or gynecologic surgery. For men, the nurse should ask specifically about prostate surgery and radiation, and for women, the nurse should obtain an obstetric history, including information about the number of pregnancies, type of delivery, any complications during delivery, and birth weights of the infants. For postmenopausal women, the nurse should inquire about estrogen replacement therapy.

Functional Assessment

Because function problems often contribute to UI, functional assessment is one of the most important parts of the evaluation. Information should be collected about the client’s ability to perform normal activities of daily living (ADLs), including grooming, dressing, getting in and out of bed, and walking. Clients who have difficulty performing these ADLs often have difficulty toileting. Functional status can be assessed by unstructured questioning or by using a structured questionnaire such as the Older Americans Research and Service Center Instrument (OARS) (Duke University Center for the Study of Aging and Human Development, 1978) or the Katz Index of ADLs (Katz et al, 1963) (see Chapter 4).

Direct observation provides the most valuable information about the client’s mobility and toileting ability. The following observational guide can be used in practice (Burgio & Goode, 1997):

1. Place the client 15 feet from the toilet.

2. Ask the client to approach the toilet, either on foot or in a wheelchair, and to prepare and position for voiding.

3. Note the time it takes the client to reach the toilet and any difficulty in getting undressed or positioning for voiding.

4. If the client is unable to toilet independently and a caregiver normally assists the client, observe the toileting procedure with caregiver assistance.

Mental status should be assessed during the functional assessment. Cognitive ability can affect the client’s ability to recognize the need to urinate, locate the toilet, and undress for toileting. In addition, knowledge of a client’s cognitive status is essential in planning nursing interventions for incontinence. The most efficient way to assess cognitive status is to use a standardized instrument such as the Folstein MiniMental State Examination (Folstein, Folstein, & McHugh, 1975) (see Chapter 4).

Environmental Assessment

Environmental barriers can contribute to UI. For example, the bathroom may be too far away or inaccessible to the client or the toilet may be too low or difficult for the client to get on and off. The client may need assistance in toileting, which may not be readily available. For these reasons, environmental assessment is an important component of the evaluation of UI. It is necessary to note the following:

• Proximity of the toilet

• Any barriers between the client’s usual location and the toilet, such as poor lighting, steps, furniture, or other objects

• The size of the bathroom: is it large enough to accommodate the client and any assistive devices (wheelchair or walker) that must be used?

• Toilet height: is it adequate or too high or low?

• Presence of grab bars, if needed

• Availability of caregiver or nursing staff assistance, if needed

• Availability of a call bell, if needed

Psychosocial Assessment

Psychosocial assessment focuses on the effect of incontinence on the client’s life and on the availability and quality of caregiver assistance. The nurse should ask the client how incontinence has affected social activities (e.g., visiting family and friends and attending social functions and church), self-esteem, mood, sexual activity, and family relationships; the nurse should also assess the client’s desire and willingness to participate in a treatment program for incontinence. Effective nursing interventions for UI require active client involvement, so motivation is an essential component of success. If a client does not want treatment for incontinence, the reasons should be explored. Is the reason, for example, a lack of knowledge; depression; or an overwhelming physical, social, or psychologic problem?

If the client depends on another person’s assistance in toileting, caregiver assessment is an essential component of the psychosocial assessment. Is the caregiver (1) physically able to assist the client, (2) available on a consistent basis, and (3) willing to assist the client? What is the caregiver’s attitude toward the client and toward incontinence? Does the caregiver have an adequate understanding of the problem and its management?

Physical Examination

The physical examination should include

• Inspection of gait and balance

• Neurologic assessment of any weakness, paralysis, or sensory deficit in the lower extremities, which can affect a client’s ability to toilet

• Abdominal examination for bladder distention, suprapubic tenderness (occurs in bladder infections), and costovertebral angle tenderness (occurs in kidney infections)

• Rectal examination for fecal impaction; rectal sensation and tone; and, for men, the size, shape, and consistency of the prostate gland

• Measurements of sitting and standing blood pressure to detect orthostatic hypotension and dizziness

• Pelvic examination, including inspection of the vagina for atrophic changes, vaginitis, cystocele, rectocele, or uterine prolapse

Tests of Provocation

Additional useful information can often be gathered by a performance of simple tests of provocation while the client has a full bladder. The physician or advanced practice nurse generally performs these during urodynamic testing. They can, however, also be performed if the client has a full bladder from drinking fluids. A number of useful tests are listed in this section. During each maneuver, the nurse should note any involuntary urine loss either by direct observation or by checking a previously applied dry absorbent pad. If the client leaks urine during any of the maneuvers, ask the client to try to stop the flow of urine. This allows the nurse to evaluate pelvic floor muscle strength:

1. Ask the client to cough 3 or 4 times while in a supine position.

2. Ask the client to stand; note any involuntary urine loss during the position change.

3. Ask the client to cough 3 or 4 times while standing.

4. If the client’s physical condition permits, ask him or her to bounce on the heels 3 or 4 times.

5. Have the client listen to running water.

6. Ask the client to walk to the bathroom.

7. Have the client wash his or her hands.

The first four of these are stress provocations, whereas the fifth and seventh are urge provocations. Leaking when walking to the bathroom can be due to urge incontinence (i.e., the client experiences an urge to void) or stress incontinence (i.e., the physical activity of walking can result in leaking in some clients with severe stress incontinence).

Bladder Habits

One of the most effective ways to assess bladder habits is to ask the client or caregiver to keep a diary of the frequency of urination and any incontinent episodes, their relative volume, and the circumstances that precipitated their occurrence (e.g., coughing, sneezing, urgency, and changing position). Fig. 28–2 shows a sample bladder diary. Bladder diaries can be used in the home, hospital, or nursing facility and can be kept by the client or caregiver. They provide a more objective and accurate measure of a client’s bladder habits than can be obtained by recall alone. They can be especially useful for a client who has short-term memory problems. If they are to be accurate, however, clients and caregivers need careful instructions on their maintenance.

FIG 28–2 Bladder diary. (Sample created by Sue E. Meiner, 2009).

Collecting bladder diaries during assessment helps establish the type of UI and aids in planning nursing interventions.

Diagnosis

The data collected during assessment and the nurse’s knowledge of UI often permit diagnosis of the client’s type of incontinence. Sometimes, however, a more complex evaluation is needed to determine the cause of and most appropriate treatment for UI. In any new case of incontinence the nurse should consider acute and potentially reversible causes. If acute incontinence is ruled out or treated and involuntary urine loss continues, a diagnosis of persistent or chronic incontinence must be considered.

The following nursing diagnoses are appropriate in clients with persistent incontinence: stress incontinence, urge incontinence, overflow incontinence, functional incontinence, and mixed incontinence.

Stress Incontinence

History: The client reports leaking urine with activities that increase intraabdominal pressure (e.g., coughing, sneezing, laughing, lifting, position changes, walking, climbing steps, or exercise).

Objective observations: Leaking urine with stress provocation; signs of pelvic floor relaxation (e.g., cystocele, rectocele, or uterine prolapse) observed on pelvic examination

Bladder records: Documentation of urine loss during physical activities that increase intraabdominal pressure

Urge Incontinence

History: The client reports a sudden urge to void, followed by involuntary urine loss; the client may also report that running water or cold weather precipitates involuntary urine loss.

Objective observations: Leaking urine with urge provocation

Bladder records: Documentation of urine loss associated with urgency; frequent urination and nocturia also frequently recorded

Overflow Incontinence

History: Client histories vary, but they often show frequent involuntary urine loss of small amounts. Urine loss may be associated with physical exertion. Complaints may include decreased force of the urine stream, hesitancy, a feeling of incomplete bladder emptying, and frequent urination of small amounts of urine. Clients may also have risk factors for urinary retention, such as diabetes or the use of anticholinergic medications.

Objective observations: An elevated PVR (greater than 100 mL) is the hallmark of overflow incontinence. This should be part of the initial evaluation of clients with UI. On abdominal examination a distended bladder may be detected on percussion or palpation. In cases in which overflow incontinence is related to prostatic hypertrophy, an enlarged prostate can be detected on rectal examination. In women a large cystocele observed during pelvic examination may suggest the cause of overflow incontinence.

Bladder records: Documentation of frequent small-volume urinary accidents

Functional Incontinence

History: The client or caregiver reports large-volume urine loss in places other than the toilet, commode, bedpan, or urinal in the absence of symptoms of stress, urge, or overflow incontinence. The client may be unaware of the need to void or have significant mobility impairment.

Objective observations: In pure functional incontinence, leaking is not seen with stress or urge provocation and the PVR result is normal. A mental status examination may reveal cognitive impairment. Functional assessment may reveal impaired mobility and toileting skills.

Bladder records: Documentation of involuntary urine loss (often large accidents) without symptoms of urge or stress incontinence

Planning and Expected Outcomes

For all types of UI the nurse must determine the client’s and caregiver’s motivation and willingness to carry out the recommended self-care practices and interventions.

Stress Incontinence

The long-term goal is that the client will reduce or eliminate the number of stress accidents. Short-term goals include

1. The client will master behavioral interventions (e.g., pelvic floor muscle exercises and stress strategies) designed to decrease the number of stress accidents.

2. The client will recognize factors that precipitate stress accidents and use interventions to prevent accidents.

Urge Incontinence

The long-term goal is that the client will reduce or eliminate urge accidents. Short-term goals include

1. The client will master behavioral interventions (e.g., pelvic floor muscle exercises, urge strategies, and bladder retraining) designed to decrease urge accidents.

2. The client will recognize factors that precipitate urge accidents and use interventions to prevent accidents.

Overflow Incontinence

The long-term goal is that the client reduces or eliminates incontinence caused by urinary retention and overflow. Short-term goals for the client vary depending on the underlying mechanism responsible for the incontinence, but they might include

1. The client will seek urologic evaluation of incontinence.

2. If the client has an acontractile bladder, the client will master in-and-out self-catheterization.

Functional Incontinence

The long-term goal is that, with caregiver assistance, the client will reduce or eliminate urinary accidents. Short-term goals for the caregiver include

1. The caregiver will master behavioral interventions designed to decrease urinary accidents.

2. The caregiver will remove environmental barriers to proper toileting.

Intervention

Nursing interventions for UI focus on behavioral therapies. In 1988 the National Institutes of Health (NIH) held a consensus conference to review the status of knowledge on UI. The conference stated, “As a general rule, the least invasive or least dangerous procedures should be tried first. For many forms of incontinence, behavioral techniques meet this criterion” (NIH Consensus Development Conference, 1990). Despite the effectiveness of these techniques, many nurses are not skilled in their implementation. The most appropriate behavioral intervention depends on the type of incontinence and a client’s cognitive status (Du Moulin et al, 2005).

Cognitively Intact Clients

Two behavioral interventions useful in cognitively intact individuals are bladder retraining and pelvic floor muscle exercises. These interventions may be used alone or in combination, depending on the type of incontinence.

Bladder Retraining

The client is encouraged to adopt a gradually expanding voiding schedule. Retraining is useful for correcting the habit of frequent toileting and for diminishing urgency. A schedule is established for voiding times, and voiding because of urgency is discouraged. This procedure is most useful for clients with urge incontinence and frequent urination.

Pelvic Floor Muscle Exercises

Pelvic floor muscle exercises were first reported as a treatment for UI by Kegel (1948). These exercises consist of alternating contraction and relaxation of the levator ani muscles, which are the muscles of the pelvic floor. These muscles, including the pubococcygeal muscle surrounding the midportion of the urethra, contract as a unit. In older adults these muscles are often weak from disuse atrophy. Performed correctly, pelvic floor muscle exercises strengthen the muscles, increase urethral resistance, and allow the client to use the muscles voluntarily to prevent urinary accidents (Wyman, 2003).

Clinicians often use verbal feedback during digital examination of the rectum or vagina to help clients identify their pelvic floor muscles. The nurse inserts two fingers into the vagina or one into the rectum and asks the client to contract the pelvic floor muscles. Approximately one third of clients are correctly able to identify and contract their pelvic floor muscles on digital examination and can use this exercise as a successful intervention for UI. The majority of older clients, however, need additional help in identifying and learning to use their pelvic floor muscles. These clients often benefit from pelvic floor muscle biofeedback. Biofeedback is not a treatment in itself, but if appropriately used, it can facilitate acquisition of the ability to contract and use the pelvic floor muscles to prevent involuntary urine loss (Burgio & Goode, 1997). During biofeedback, the client is given immediate auditory and/or visual feedback of pelvic floor muscle contractions.

A variety of techniques, including vaginal probes, rectal probes, and surface electromyography, have been used to provide biofeedback. This therapy is more effective when used in conjunction with Kegel exercises.

After training with biofeedback or verbal feedback, the client must practice pelvic floor muscle exercises at home. The client should be instructed to practice contracting and relaxing the pelvic floor muscles at least 45 times a day, in three or four practice sessions. The client should exercise lying down, sitting, and standing. This facilitates the client’s ability to identify and use the muscles in any position. The nurse should remind the client to relax the abdominal muscles when exercising as this is essential for successful performance of exercises. The nurse can ask clients to try occasionally to slow or stop their urine stream while voiding. This allows them to monitor their progress in using and strengthening the correct muscles (Box 28–2).

BOX 28–2 PELVIC FLOOR MUSCLE EXERCISE INSTRUCTIONS