8.10 Urinary Incontinence

Urinary incontinence refers to the involuntary loss of urine. Contrary to common misconceptions, urinary incontinence is not a normal consequence of aging or childbirth. Urinary incontinence can significantly affect a person’s participation in social activities and cause them emotional distress. It often goes underreported due to feelings of embarrassment, making it critical for nurses to assess for signs and symptoms of urinary incontinence and encourage appropriate treatment.

There are many types of urinary incontinence. Common types are stress incontinence, urge incontinence, overflow incontinence, and functional incontinence. See Table 8.10a for a comparison of these types of incontinence.^[1]

Table 8.10a. Common Types of Urinary Incontinence^[2],[3],[4]

As described in Table 8.10a, urinary incontinence can be caused by numerous factors. As individuals get older, changes in bladder muscle tone and function and weakened pelvic floor muscles can increase the incidence of urinary incontinence. Women are prone to urinary incontinence due to factors such as pregnancy, childbirth, and menopause, which can weaken pelvic floor muscles. Obesity can also predispose an individual to urinary incontinence because excess weight can put increased pressure on the bladder and pelvic floor muscles, leading to stress incontinence. Other medical conditions like chronic constipation and neurological disorders also increase the risk for urinary incontinence.^[5],[6],[7]

Assessment

While urinary incontinence primarily affects the urinary system, its clinical manifestations can involve various body systems. See Table 8.10b for a summary of clinical manifestations associated with urinary incontinence.

Table 8.10b. Clinical Manifestations of Urinary Incontinence^[8],[9],[10]

Diagnostic Testing

Diagnostic testing for urinary incontinence involves various assessments and examinations to identify the type of incontinence, severity, and potential underlying causes. Urinalysis may be performed to assess for infection, and BUN and creatinine levels may be performed to assess kidney function. For example, kidney function may be impacted if overflow incontinence occurs due to urinary retention. Review normal reference ranges for common diagnostic tests in “Appendix A – Normal Reference Ranges.”

Diagnostic imaging and urodynamic studies may be performed. Postvoid residual amounts may be measured to determine the amount of urine remaining in the bladder after voiding. This measurement can be obtained by a bladder scan, ultrasound of the bladder, or with urinary catheterization.

Clients are encouraged to complete a bladder diary in which they record fluid intake, voiding times and amounts, and episodes of incontinence episodes as part of the assessment process.

Nursing Diagnoses

Nursing diagnoses for clients with urinary incontinence guide nursing care and address the specific needs of individuals. Common nursing diagnoses include the following:

• Risk for Impaired Skin Integrity
• Anxiety
• Risk for Infection
• Self-Care Deficit
• Readiness for Enhanced Knowledge

Outcome Identification

Outcome identification includes setting short- and long-term goals and creating expected outcome statements customized for the client’s specific needs. Expected outcomes are statements of measurable action for the client within a specific time frame that are responsive to nursing interventions. Examples of expected outcomes for clients with urinary incontinence are as follows:

• The client will describe skin care measures, such as cleansing and properly drying of the perineal area after episodes of incontinence to reduce the risk of skin breakdown, following the teaching session.
• The client will describe effective strategies for preventing urinary incontinence following the teaching session.

Interventions

Medical Interventions

Medical interventions for incontinence aim to manage and treat the underlying causes of urinary incontinence and may include bladder training, pelvic floor muscle exercises, medication therapy, medical devices, or surgery. Additionally, intermittent catheterization may be prescribed for overflow incontinence caused by urinary retention.

Bladder Retraining

Bladder retraining involves scheduled voiding and then gradually extending the time between voids to increase bladder capacity and reduce the brain’s urgent response to signals from bladder filling.

Pelvic Floor Muscle Exercises

Pelvic floor muscle exercises, including Kegel exercises, strengthen the pelvic floor muscles and can improve bladder control, especially in cases of stress incontinence. Clients may be referred to physical therapy for pelvic floor rehabilitation exercises.

Medication Therapy

Medications may be prescribed, depending on the type of urinary incontinence:

• Anticholinergics/Antispasmodics: Medications like oxybutynin, tolterodine, or solifenacin help relax bladder muscles and reduce urinary urgency in cases of urge incontinence.
• Alpha-blockers: In men who have urge incontinence or overflow incontinence, alpha-blockers like tamsulosin may be prescribed to relax the bladder neck muscles and muscle fibers in the prostate and make it easier to empty the bladder.
• Estrogen Therapy: Estrogen may be used in postmenopausal women to improve poor urethral tone causing stress incontinence.

Medical Devices

Pessaries are medical devices that are inserted into the vagina to support the bladder in cases of stress incontinence. Urethral inserts are small devices inserted into the urethra before activities that might trigger leakage, acting as a barrier to prevent urine leakage.

Surgery

Surgical placement of a sling or mesh under the urethra or bladder neck may be performed for support of these structures and reduction of stress incontinence. A bladder neck suspension procedure may be performed to support the urethra and bladder neck.^{[11],[12],[13]}

Nursing Interventions

Nursing interventions for urinary incontinence focus on empowering individuals to improve bladder control and provide emotional support.

Health Teaching and Health Promotion

Health teaching is provided about possible factors contributing to urinary incontinence, such as bladder irritants (such as caffeine and alcohol). Educate clients and caregivers on proper perineal hygiene to prevent skin breakdown and infections due to constant moisture from incontinence. Incontinence products, like absorbent pads, briefs, or bed protectors may be used to manage leaks, and barrier creams may be applied to protect the skin from irritation.

Based on the type of incontinence, bladder training techniques may be helpful. For example, scheduled voiding and gradually increasing time between voids may be helpful to improve bladder control and reduce the sensations of urgency.

Evaluation

During the evaluation stage, nurses determine the effectiveness of nursing interventions for a specific client. The previously identified expected outcomes are reviewed to determine if they were met, partially met, or not met by the time frames indicated. If outcomes are not met or only partially met by the time frame indicated, the nursing care plan is revised. Evaluation should occur every time the nurse implements interventions with a client, reviews updated laboratory or diagnostic test results, or discusses the care plan with other members of the interprofessional team.