Copyright 2009 by Health Professions Press, Inc. All rights reserved.

Contents

About the Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Foreword Diana J. Mason, Ph.D., R.N., F.A.A.N.. . . . . . . . . . . . . . . . . . xiii Foreword Joseph G. Ouslander, M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . xv Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxiii 1 2 3 4 5 6 7 8 9 10 11 12 13 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Problem of Incontinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Understanding Bladder and Pelvic Floor Function . . . . . . . . . . . . . Causes of Incontinence and Identification of Risk Factors. . . . . . . . 1 13 61 85

Bowel Dysfunction and Its Relationship to Urinary Incontinence . . 129 Clinical Assessment and Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . 175 Self-Care Practices and Lifestyle Changes to Reduce Urinary Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233 Behavioral Treatments: Implementing Toileting, Bladder Training, and Pelvic Floor Muscle Rehabilitation Programs . . . . . . . . . . . . . . 245 Drug Therapy for Incontinence and Overactive Bladder . . . . . . . . . 307 Urinary Collection and Management Products . . . . . . . . . . . . . . . . 365 Evaluation and Management of Pelvic Organ Prolapse . . . . . . . . . . 485 Overview of Surgical Intervention for Incontinence . . . . . . . . . . . . 523 Continence Nurse Specialists and Service Models . . . . . . . . . . . . . . 565

Appendix A: Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 585 Appendix B: Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 601 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 615

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Copyright 2009 by Health Professions Press, Inc. All rights reserved.

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CONTENTS

Patient & Provider Tools & Forms CD-ROM

Care Plans
Care Plan #1 Nursing DiagnosisUrinary Elimination: Altered Patterns Related to Transient/Acute Causes of Incontinence Care Plan #2 Nursing DiagnosisUrgency Urinary Incontinence and Overactive Bladder Symptoms of Urgency and Frequency That May Be Secondary to Detrusor Overactivity Care Plan #3 Nursing DiagnosisStress Urinary Incontinence Related to Decreased Outlet Resistance from Weakened or Damaged Urinary Sphincter and/or Pelvic Floor Muscle Care Plan #4 Nursing DiagnosisUrinary Retention Related to Chronically Overfilled (Distended) Bladder with Loss of Sensation Care Plan #5 Nursing DiagnosisFunctional (Urinary or Bowel) Incontinence Related to Decreased Physical or Cognitive Capability Care Plan #6 Nursing DiagnosisImpaired Skin Integrity Related to Urinary and/or Bowel Incontinence Care Plan #7 Nursing DiagnosisUrinary Tract Infection, Potential for, Related to Urinary and Bowel Incontinence Care Plan #8 Nursing DiagnosisUrinary Tract Infection, Potential for, Related to Use of Indwelling (Urethral or Suprapubic) Catheter Care Plan #9 Nursing DiagnosisConstipation, Colonic, Related to Lack of Dietary Fiber, Fluid Intake, and Exercise Care Plan #10 Nursing DiagnosisConstipation, Perceived, Related to Stool (Fecal) Impaction Care Plan #11 Nursing DiagnosisBowel Incontinence Related to Decreased Rectal Tone Care Plan #12 Nursing DiagnosisDiarrhea Related to Laxative and Medication Use and Bacterial Infection

Patient Education Tools

What Is Urinary Incontinence? Preventing Bladder Infections What to Know About Your Bladder and Voiding Caffeine Count What You Eat and Drink Can Affect Your Bladder Bladder TrainingControlling Urgency and Frequency Exercising Your Pelvic Floor Muscles Getting the Knack for Stopping Urine Leaks Doing a Pad Test Ways to Prevent Bladder Problems During the Night Helping Your Bladder to Empty How to Prevent Postvoid Dribble The Side Effects of Treatment for Overactive Bladder Using a CatheterMen Using a CatheterWomen
Copyright 2009 by Health Professions Press, Inc. All rights reserved.

CONTENTS

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Care and Use of an Indwelling (Foley) Urinary Catheter How to Use an External Condom Catheter How to Care for Your Catheter Drainage Bag Using a Pessary for Pelvic Organ Prolapse Using Topical Estrogen Tips for Keeping Your Bowels Moving Self-care for Painful Bladder Syndrome (Interstitial Cystitis)

Assessment Forms
Incontinence Patient Profile Past Medical History Pelvic Floor Muscle Strength Assessment Daily Voiding and Incontinence Record Voiding FrequencyVolume and Incontinence Chart Bowel Disorders Profile Daily Bowel Record Treatment Findings and Recommendations Pelvic Floor Muscle Exercise Prescription Initial Consultation (Long-term Care) Bladder and Bowel DiaryAssessment of Bladder Function (Long-term Care)

Information Boxes
2.2 5.1 5.2 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 6.9 7.1 9.1 10.1 10.3 10.5 11.2 Summary of criteria for facility compliance with Tag F315 (Urinary Incontinence and Catheters) Bowel Function Evaluation Checklist Elements of a successful bowel program in long-term care Evaluation checklist Evaluation checklist in long-term care residents Simple UI-related questions Patient Perception of Bladder Condition (PPBC) Q-Tip procedure Examiner instructions on how to perform a pelvic floor muscle (PFM) contraction during digital pelvic examination of female patients Applications of a portable ultrasound machine (the BladderScan) in long-term care Urodynamics terminology Procedure for bedside or eyeball cystometrogram Key components of lifestyle changes Assessment of drugs used in the treatment of voiding dysfunction Product Classification and Approval in the United States Indications (medical necessity) for indwelling catheter Medicare medical necessity and documentation requirements for intermittent catheters Pelvic Organ Prolapse Quantification (POPQ) Measurement
Copyright 2009 by Health Professions Press, Inc. All rights reserved.

CONTENTS

Perineal skin care Step-by-step approach to indwelling catheter removal Best practices for indwelling urinary catheters Changing a suprapubic catheter Steps of a prompted voiding program International Consultation on Incontinence Questionnaire (ICI-Q)

Tables
4.1 4.4 4.6 Lower urinary tract symptoms (LUTS) Medications that affect bladder function Common diagnoses and definition of terms for bladder and urethral dysfunctions 5.2 Common medications used for chronic constipation 6.1 OAB-q 6.2 Description of specific urodynamic studies 8.1 Description of types of bladder programs 8.2 Possible contributions and solutions to UI in patients with dementia 9.3 Drug therapy for underactive bladder and incomplete bladder emptying 9.4 Drug therapy for stress urinary incontinence 9.5 Estrogen hormone preparations 10.2 Common perineal skin conditions Appendix 9.1 Appendix 9.2 Appendix 9.3 Appendix 10.1 Appendix 10.2 Appendix 11.1 Drug therapy for overactive bladder and urinary incontinence OAB drug efficacy OAB drug side effect profile Product (HCPC) billing codes (as of 2008) Review of current skin care products Review of pessary types

Figures
6.1 6.6 6.9 6.10 6.12 8.4 Diagnostic algorithm for evaluation of urinary incontinence (UI) Female body map and a pain scale for patient to mark pelvic pain Pelvic floor muscle strength assessment Male body map and a pain scale for patient to mark pelvic pain UI care pathway Management pathway for urinary incontinence in a long-term care setting 8.5 Urgency suppression wave 10.1 Types of incontinence products according to absorbency 11.5 Pelvic organ prolapse quantification

Copyright 2009 by Health Professions Press, Inc. All rights reserved.

Preface

Urinary incontinence (UI) is a complex and costly medical condition. UI combined with overactive bladder (OAB) comprise two of the ten most chronic conditions in women in the United States, and they affect a higher percentage of individuals of all age groups than do hypertension, depression, or diabetes. UI and OAB affect the social, psychological, occupational, domestic, physical, and sexual lives of women and men of all ages and are increasingly adding to caregiver burden. The symptoms of UI and OAB are historically underreported because individuals perceive that current treatment is ineffective and that the symptoms are a normal consequence of aging or childbirth. People also feel embarrassment regarding these two conditions. The lack of knowledge on the part of clinicians about the causes and management options, and their assumption that UI and OAB are not true medical issues, hinder the detection and treatment of these insidious conditions. This book provides a comprehensive review of the problem of UI and OAB for health care providers of all disciplines (nurses, doctors, allied health professionals) who practice in primary care and who provide services to adults in acute care, rehabilitation centers, home care, and long-term care settings. This second edition of Managing and Treating Urinary Incontinence is unique in that it combines the expertise of a nurse practitioner (DKN) and a urologist (AJW), both of whom are authorities on UI and who blend their knowledge and perspective to present a thorough and practical review of the management and treatment of UI. Since the first edition of this book, significant advances have been made in the management and treatment of UI. Professional organizations, government agencies, and consumer groups worldwide have developed practice guidelines on UI. In the United States, the 2008 National Institutes of Health State-of-the-Science Conference Statement on the Prevention of Fecal and Urinary Incontinence in Adults noted that preventive strategies need to be targeted to specific populations or clinical groups and should examine the impact of public health initiatives, increased public and provider awareness, changes in reimbursement mechanisms, and health delivery redesign. However, most health care providers are unaware of the existence of guidelines or consensus statements and thus have not incorporated them into their care practice.

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Copyright 2009 by Health Professions Press, Inc. All rights reserved.

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Additionally, we continue to see an increase in research initiatives to determine the best treatment for UI so that providers can practice evidencebased care. Federal agencies have funded multiple research projects that look at the use of noninvasive behavioral treatments in ambulatory and long-term care settings. The National Institute of Diabetes and Digestive and Kidney Diseases has funded multisite networks that conduct research on UI, pelvic floor prolapse, and interstitial cystitis. The development of new drug therapy for OAB and innovative surgical approaches for incontinence and other pelvic floor problems have expanded the choices of treatments available to men and women. Research outlining the causes of UI and how to diagnose the condition has concluded that UI is treatable, even curable, and can always be managed to improve quality of life; however, the fact remains that men and women do not seek treatment. In order to provide care for patients with UI, a few prerequisites must exist. First, a clinician must determine if incontinence or any lower urinary tract dysfunction exists and if the individual wants treatment. There is a stigma attached to UI and OAB, and people face social and personal barriers to admitting that they are bothered by these conditions. As health care providers, we must understand that individuals, especially women, despite their age, do not view UI as abnormal. Health care providers, doctors, and nurses must take the initiative and ask their patients the all-important questions, Do you ever leak urine? Do you control your bladder or does your bladder control you? We must begin to address the issues of UI and OAB because we will encounter the problems more frequently in our professional and personal lives as baby boomers age. Chances are that in the coming decades each of us will be in a position of caring for a family member who experiences incontinence. We must find the solutions and approaches to this problem now before it becomes an epidemic! Providers need to increase the dialogue about UI and OAB with their patients, colleagues, and friends because these conditions are costly, embarrassing, and distressing to society as a whole. The second prerequisite is that clinicians must have a knowledge base from which to diagnose men and women with UI and OAB. This is one of the main objectives of the second edition of this book. Our colleagues tell us that they usually do not inquire about UI because, other than recommending an absorbent product, they are unsure of what else to tell people (they just dont know). This book provides readers with the basics to confidently discuss the most current and accurate information on UI with their patients and to initiate treatment. The book provides a comprehensive overview of UI, cites in detail the prevalence and risk factors (Chapter 2), and provides a thorough discussion of the anatomy and physiology of the lower urinary tract (Chapter 3). Chapters 4 and 6 are devoted to the causes of UI and the primary and secondary evaluation that should be done prior to initiation of treatment. Chapter 5 discusses the relationship between bowel function and UI. A major strength of this book is Chapters 7, 8, 9 and 12, which provide a very detailed

Copyright 2009 by Health Professions Press, Inc. All rights reserved.

PREFACE

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review of the current treatments for UI and OAB. These chapters outline practical strategies for preventing UI; detail behavioral, drug, and surgical treatments; and provide the most current evidence-based outcomes research. This second edition also includes an expanded review of the use of catheters, including products and devices that can be used to manage UI as well as extensive illustrations and pictures of these products (Chapter 10). New to this edition is Chapter 11, which addresses pelvic organ prolapse in women and details the use of pessaries. The third prerequisite is that clinicians must know where to go to find more information that will assist them in providing the most current care for UI. Appendix B (Resources) provides a list of companies that supply treatment products as well as a list of organizations that can offer support. For readers who are unfamiliar with terminology related to urinary and fecal function, incontinence, and the devices and strategies used to manage UI, an extensive glossary is provided (Appendix A). This edition also includes a CD-ROM that provides printable forms that can be used in the assessment of UI as well as helpful education tools that can be given to patients to enhance self-treatment and self-management of UI. Many of the chapter tables are also included on the CD-ROM so that clinicians can print them for reference and use them in clinical practice. In addition, several care protocols and forms are included on the CD-ROM that we have found to be useful in assessment, treatment, and management and that are often requested by colleagues and lecture/seminar attendees. Our goal has been to make the second edition of Managing and Treating Urinary Incontinence a comprehensive, practical book that can be used in all care settings: acute care, primary care, home care, and long-term care. We hope that readers come away from this book better informed and inspired to approach the problems of UI and OAB with greater confidence, empathy, and energy.

Copyright 2009 by Health Professions Press, Inc. All rights reserved.