Centers for Medicare and Medicaid Services

Urinary Incontinence and Catheters Satellite Broadcast

October 27, 2004

Causes of Urinary Incontinence

Urinary tract conditions Neurological disorders Impaired functional status Environmental barriers

Potentially Reversible Causes of Urinary Incontinence

Acute symptomatic urinary tract infection Atrophic vaginitis Severe constipation and fecal impaction Conditions that cause a decrease in

mobility and toileting ability Caffeine intake Drug side effects

Urge Incontinence “Overactive Bladder”

Signs: • Urine loss Urine loss • Urgency Urgency • Frequency > 8x/24 hrsFrequency > 8x/24 hrs

• Involuntary Bladder Contractions

• Severe Bladder Hypersensitvity

Stress IncontinenceStress Incontinence

Increase in intra-abdominal pressureIncrease in intra-abdominal pressure

Symptoms: Symptoms: Small losses of urine when:Coughing LaughingExercisingChanging positions

Overflow Incontinence Urethral Obstruction

Enlarged prostateUrethral StrictureFecal Impaction

Neurologic ConditionsDiabetic NeuropathyLow Spinal Cord Injury

MedicationsAnticholinergics

Symptoms Bladder Distention Reduced Urine Flow

Dribbling Frequency

Functional Incontinence

Conditions:Conditions:

Cognitive ImpairmentCognitive Impairment

Chronic Functional Chronic Functional DisabilityDisability

Psychological Psychological ImpairmentImpairment

Environmental Environmental BarriersBarriers

Symptoms:Symptoms:

Inaccessible toilet Inaccessible toilet or lack of staff or lack of staff assistanceassistance

Nocturnal enuresisNocturnal enuresis

Combined fecal Combined fecal and urinary and urinary incontinenceincontinence

Objectives of the Assessment

Identify causes and contributing conditions

Co-morbid conditions and medications

Degree of bother to resident Resident and family preferences for

treatment

Goals of Assessment1. Determine if the resident is incontinent,

nature of lower urinary tract symptoms, and type of incontinence

2. Determine the type of assessment conducted of the resident’s incontinence status before admission and any interventions

3. Determine reversible factors4. Determine conditions that may require further

evaluation5. Implement a prompted voiding trial6. Determine resident’s risk for complications and

preferences for treatment

Reversible Causes of UI Delirium Impaired mobility Infection Fecal impaction Frequent urination Medications

Key Elements to Include in Resident’s History Duration and characteristics of the

incontinence Precipitants Voiding patterns Previous treatment and/or

management

Factors that Increase Resident’s Risk for UI

Impaired cognitive function Impaired mobility Decreased manual dexterity Poor upper and lower extremity strength Visual problems Neurological conditions Medications

Factors that Increase Resident’s Risk for UI

Medications: Diuretics Narcotics Anticholinergics Psychotropics (Sedatives,

Hypnotics, Antipsychotics) Calcium channel blockers

General Physical Assessment

Neurological conditions Mobility Cognition Manual dexterity

General Physical Assessment

Abdominal: Bowel sounds Surgical incisions Masses Suprapubic bladder fullness

General Physical Assessment

Female Perineum: Atrophic tissue changes Pelvic organ prolapse Perineal skin condition Color, odor, discharge Structural abnormalities

General Physical Assessment

Perineal assessment for men: Determine lesions of the shaft/skin Inspect scrotum for lesions and

size

Additional Testing

Urinalysis - clean catch Nursing home residents should not be catheterized

to collect a urine specimen unless it is an urgent situation

Testing to exclude a UTI should only be done if the incontinence is new or worsening, or other symptoms of UTI

Post-Void Residual (PVR) Risk factors: all men, diabetes, neurological

disorders, medications

How to Perform PVR

PVR: Conduct within a few minutes of

voiding Record voided and PVR volume Done through sterile in-and-out

catheterization or bladder ultrasound

Behavioral Programs

Required skills for residents: Ability to comprehend and follow

education and instructions Identify urinary urge sensation Learn to inhibit or control urge to

void Kegel exercises

Bladder Rehabilitation or RetainingResident: Should be able to resist or inhibit the urge

to void Void according to a timetable Independent in activities of daily living Experience occasional incontinent episodes Aware of need to void Usually assessed as having urge

incontinence

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Bladder Muscle - Detrusor

Urethra

Pelvic Floor Muscle

Lower Urinary Tract

Habit Training/Scheduled Voiding

Requires scheduled toileting, at regular intervals, on a planned basis, and match the resident’s voiding habits

Maintain record of resident’s voiding patterns

Prompted voidingResident: Assessed with urge incontinence Cognitive impairment Dependent on facility staff for

assistance Able to say name or reliably pint to

one of two objects Requires training, motivation, effort

Risk of Complications for Indwelling Urinary Catheter Bacteriuria Febrile episodes Bladder stones Epididymitis Chronic renal inflammation Pyelonephritis

Assessment to Determine if Indwelling Catheter is Medically Justified

Used for short-term decompression of acute urinary retention

If used beyond 14 days, restrict to-• Urinary retention not managed by other means• Presence of multiple pressure ulcers for which

healing is compromised by urinary incontinence• Pain or impairment is compromised

Assessment to Determine if Indwelling Catheter is Medically Justified

If indwelling urinary catheter is not medically justified-

Remove catheter Complete a voiding trial Determine best bladder management

program for resident

Risk Factors for Urinary Tract Infections Fecal incontinence Urinary retention Diabetes Structural abnormalities of the

lower urinary tract Atrophic vaginitis in women

Asymptomatic Bacteriuria Common in geriatric population Should not be treated

Unnecessary risks of antibiotic therapy Excess costs Potential to develop multi-drug resistant

bacteria

Symptomatic Urinary Tract Infections (UTIs)Residents without an indwelling urinary catheter include at least three of the

following: Fever of at least 2.4 degrees Fahrenheit

above the resident’s baseline temperature New or increased incontinence, burning or

pain on urination, frequency or urgency New flank pain or tenderness Change in character of urine such as blood,

new pyuria or hematuria Worsening of mental or functional status

Symptomatic Urinary Tract Infections (UTIs)Residents with an indwelling urinary Catheter include at least two of the following :

Fever of at least 2.4 degrees Fahrenheit above the resident’s baseline temperature

New flank pain or tenderness Change in character of urine such as

blood, new pyuria or hematuria Worsening of mental or functional status

Assessment for Absorbent Products

Assess resident’s; Functional ability to ambulate, toilet,

disrobe, use of assistive devices Ease in self-toiletingAssess product for: Contain urinary leakage Comfort Ease of application/removal

Bladder Rehabilitation/Retraining

Goal is to achieve a normal voiding pattern, or

Achieve the longest possible interval

Resident should be able to hold urine until reaching the toilet

Prompted Voiding

Three components:

regular monitoring with encouragement prompting the resident to toilet on a

scheduled basis praise and positive feedback when the

resident is continent and attempts to toilet.

Prompted Voiding (PV)Predictors of responsiveness to PV

Resident’s response to a therapeutic trial of PV

Normal bladder capacity (>200 and <700cc) Recognizes need to void Baseline incontinence < 4 times/12hours Maximum voided volume > 150 cc Post void residual < 100 cc Able to void successfully when given

toileting assistanceEvidence from properly designed and implemented

controlled trials by University of Iowa Gerontology Nursing Intervention Research Center

Habit Training/Scheduled Voiding

Goal is to prevent incontinence fromOccurring:

Provide access to the toilet based on the

resident’s voiding pattern

Key Considerations for Medication Therapy for Urge Incontinence and Overactive Bladder

Identify residents with symptoms known to be responsive to medication therapy

Ongoing incontinence despite treatment of reversible causes

Risk for anticholinergic side effects Costs

Anticholinergic Medications

Side Effects: Dry mouth Constipation Development or exacerbation of

gastroesophageal reflux Urinary retention Impaired cognitive function Delirium

Determination of Urinary Tract Infection

Review several test results in combination with

clinical findings: Microscopic urinalysis showing the

presence of pyuria; or Positive urine dipstick test for leukocyte

esterase (indicating significant pyuria) or Nitrites (indicating the presence of

Enterobacteriaceae)

Determination of Urinary Tract Infection

Nonspecific symptoms, look for: Hematuria, Fever or Evidence of pyuria

Urinary Tract Infection Prevention Strategies

Infection control policies and procedures

Identification of high risk residents Perineal hygiene, especially for

women with fecal incontinence Hydration Treatment of atrophic vaginitis

Complications of Indwelling Catheters

Urinary Tract Infections Encrustations Leakage around catheter Inadvertent removal of catheter

Catheter Related Urinary Tract Infections

Risk method and duration of catheterization quality of catheter care host susceptibility

Most common complication seen with long-term use of indwelling catheters

MRSA E-coli most common organism Urosepsis –results from frequent and

repeated UTIs

Encrustations

Risk factors: alkaline urine poor mobility decreased fluid intake

Leakage Around Catheter

Contributing factors: Detrusor (bladder) overactivity Infection Urethral/catheter obstruction Catheter or balloon size too large Constipation or fecal impaction

Other Care Practices to Reduce Complications Educating the resident or responsible

party on the risks and benefits of catheter use;

Recognizing and assessing for symptoms of complications;

Attempts to remove the catheter; Monitoring for post void residual; and Keeping the catheter anchored to

prevent urethral tensions

Skin Problems Related to Urinary Incontinence

Early: Irritant dermatitis Inflammation Caused by prolonged

contact with moisture

Advanced: Blistering Erosion Exudate

Decline or Lack of Improvement in Continence

Practices that prevent or minimize a decline or lack of improvement:

Assessment and documentation of the resident’s

baseline continence status Interventions to improve functional abilities Environmental modifications Treatment of the underlying cause Adjustment of medications Fluid management program

Websites

Qualidigm Medicare Information http://www.ctmedicare.org/qip_med_nursing_res.shtml

AHRQ National Guideline Clearinghouse http://www.guideline.gov/ National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

http://kidney.niddk.nih.gov/kudiseases/topics/incontinence.asp Society of Urologic Nurses and Associates http://www.suna.org/ National Association for Continence http://www.nafc.org/ The Simon Foundation for Continence http://www.simonfoundation.org/html/