Sunday, May 12, 2013

Life, Uninterrupted: Nurses can help patients keep urinary incontinence from becoming burdensome

For decades, public health initiatives successfully have changed the public’s perceptions and personal behaviors regarding a range of health conditions including lung cancer, heart disease, osteoporosis and HIV. Yet past initiatives to enlighten the public about a health condition that can limit quality of life severely as people age have failed to catch fire. The condition, which affects one in three women and costs the country more than $19 billion per year, is urinary incontinence. “The problem with incontinence as a public health initiative is that it has not been terribly successful,” said Mikel Gray, RN, PhD, FNP-BC, PNP-BC, CUNP, CCCN, FAANP, FAAN, a leading nurse expert and researcher on UI and a clinical professor of nursing at the University of Virginia School of Nursing in Charlottesville. “Continence and voiding behavior are more intensely private than almost anything else in our culture.” Gray is a clinical faculty member within the Department of Urology.

Indeed, it seems one of the few times Americans openly talk about urination is during child rearing when parents share stories about toilet training. But when it comes to adult bladders that leak or need to be emptied too often and in an urgent rush, the conversation stops.

Women and men of all ages can start learning the simple techniques and lifestyle changes to prevent and treat lower urinary tract symptoms such as stress UI and urgency UI, and a group of dedicated healthcare professionals is ramping up public education efforts to help spread the word. In 2010 experts in urology, urogynecology, nursing and behavioral health gathered to fashion a new public health initiative that focuses on the importance of healthy bladder habits on overall health, rather than narrowing in on just continence and incontinence, said Gray, who was one of those experts. The group decided “a consensus statement was necessary to raise awareness among the general public, healthcare providers, payors and policymakers, with the goals of minimizing the impact of poor bladder health and stimulating primary prevention of bladder conditions,” according to an article in the October 2011 issue of the International Journal of Clinical Practice.
Separating fact from fiction

“The impact of poor bladder health on society is not fully appreciated by most healthcare professionals or the general public, including the affected individuals …” the consensus article states.

The perception that urinary incontinence and overactive bladder are inevitable and irreversible is almost as common among healthcare providers as it is among the general public, said Diane K. Newman, RN, DNP, CRNP, BCB-PMD, FAAN, a research investigator and clinician, adjunct associate professor in the school of medicine and co-director of the Penn Center for Continence and Pelvic Health at the University of Pennsylvania Medical Center in Philadelphia. She also is a member of the expert consensus group.

One of the first lessons to be learned about bladder health is that UI and overactive bladder are not unavoidable as people age, and they are largely preventable conditions — even in the elderly. T. Maria Jones, RN, BS, CWOCN, DAPWCA, FMNLI, teaches staff nurses at Kennedy University Hospital in Cherry Hill, N.J., that it is wrong to assume elderly patients need adult briefs while hospitalized. “It is important to do a focused assessment on each patient,” she said. “I want nurses to develop a plan of care that matches what the patient was doing at home.” Jones, a wound care specialist, was named Wound/Ostomy/Continence Nurse of the Year by the United Ostomy Associations of America Inc. this year.

Patients should be assessed for their voiding patterns and habits at home, Jones said. For example, do they have the mobility to get up and use the bathroom and were they using collection devices, such as bedside commodes or panty liners, she said. When hospitalized, patients automatically lose mobility because of bedrails, catheters or cluttered rooms. “We need to maintain patients’ dignity and only use disposable products if absolutely necessary,” Jones said. “We have to be clear with the terms we are using with patients and not embarrass them by treating them like children. Putting a brief on an adult can be humiliating.” The second leading cause of nursing home placement is incontinence, which family members and other caregivers find difficult to cope with, Jones said. But if incontinence can be controlled in the hospital, it is possible to prevent the elderly from being placed in nursing homes.

The healthcare professionals interviewed for this story say primary prevention needs to take a higher priority than secondary and tertiary treatment, where most of the research emphasis has been placed until now.

Newman is working with Carolyn Sampselle, RN, PhD, ANP, FAAN, from the University of Michigan (another member of the consensus group) as principal investigators in an NIH/NINR funded incontinence prevention study called Translating Unique Learning for Incontinence Prevention. The five-year TULIP study is a prevention program that teaches women about low-risk self-management practices such as lifestyle changes, bladder training and pelvic floor muscle exercises. The study will measure the effectiveness of two interventions: a bladder health class and a bladder health DVD.

They are recruiting 600 women who are older than 55; are not taking overactive bladder medication; and either do not have incontinence, do not leak urine or only slightly leak urine. The women will be followed for a two-year period. “We have had an overwhelming response to our TULIP study,” Newman said. “When asked, women say they want to enroll in the study because they know of someone who has ‘bladder control issues’ and they want to learn what to do so they do not develop those same problems.”

Julie Tupler, RN, president of Diastasis Rehab (, said pelvic floor muscle exercises, not medications, are the answer to preventing and treating stress UI and urgency UI. “Incontinence is primarily muscular,” she said. Tupler said education about strengthening the pelvic floor muscles with exercises using resistance, more commonly known to women as Kegels, should begin early in a woman’s life and well before having children. “You wouldn’t run a race and not train, would you?” Tupler said. “Tone them and practice how you use them. At birth, you need to know how to relax the pelvic floor muscles that you have strengthened during pregnancy.”

For the initial management of stress, urgency and mixed UI, lifestyle modifications, such as weight loss, elimination of bladder irritants from the diet, bladder training, interventions and pelvic floor muscle training are recommended by the Adult Conservative Management Committee of the 2008 International Consultation on Incontinence. Medications are listed as the last choice for management of overactive bladder and urgency UI. “One out of three women report stress incontinence five years after childbirth whether or not they have another child, so nurses have to ask ‘Are you having problems with your bladder? Do you have any leakage when you laugh, cough or sneeze? Do you wear pads and, if so, why?’” Newman said. The strains of pregnancy and labor and delivery on pelvic floor muscles predispose women to stress UI and urgency UI. But preparing the muscles before pregnancy can prevent these problems, especially later in life, Tupler said.

Many women are taught incorrectly how to do pelvic floor muscle exercises, said Edna Moore, RN, MSN, ARNP, WHNP-BC, who works as a practitioner and nurse researcher in the continence clinic at the VA Medical Center in Atlanta. “Most people are taught to quickly squeeze and relax, squeeze and relax. “But that doesn’t strengthen the muscles,” she said. “The squeeze should be held for up to 15 seconds. We teach a 15-second squeeze, a 15-second rest, repeat that 15 times and do that three to four times per day. Most people use their abdominals, but you need to relax the abs and squeeze only the pelvic floor,” she said. “The second correction is to gradually lengthen the time you squeeze the pelvic floor muscles, eventually holding for up to 15 to 20 seconds with each squeeze and resting for the same amount of time in between each squeeze.”
Primarily a female issue

Although men experience UI, often because of problems related to the prostate, twice as many women are affected, making it a largely female issue. Women should start exercising the pelvic floor as soon as they understand what the pelvic floor muscles are, Moore said. And it is never too late to learn. “I’ve had 95- and 97-year-olds in the clinic, and we teach them these as well.” Even women whose pelvic floor muscles are weakened because of chronic conditions such as multiple sclerosis, still can benefit from the exercises, although it will take longer to see the effects, Moore said. However, stress UI caused by structural problems, such as urethral hypermobility, may not be resolved by pelvic exercises and often requires surgery, she said. Nurses have an important role in filling the knowledge gap about UI, the nurse experts say. “Nurses are still primarily women, and this is a female issue,” Newman said.

To learn more information about the TULIP Study, call 215-615-3780 or email Newman

Janet Boivin, RN, BSN, BA, is a freelance writer. Post a comment below or email


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