Assessment and management of urinary incontinence in women

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1 PEER-REVIEWED ontinene / CPD evidene & pratie Why you should read this artile: To update your knowledge of the types of urinary inontinene affeting women, potential effets of symptoms on patients quality of life, and treatment options To ensure ontinene are is holisti and onsiders the needs of the patient To ount towards revalidation as part of your 35 hours of CPD, or you may wish to write a refletive aount (UK readers) To ontribute towards your professional development and loal registration renewal requirements (non-uk readers) Assessment and management of urinary inontinene in women Ellie Stewart Citation Stewart E (2018) Assessment and management of urinary inontinene in women. Nursing Standard. doi: / ns.2018.e11148 Peer review This artile has been subjet to external double-blind peer review and heked for plagiarism using automated software Correspondene ellie.stewart@gstt.nhs.uk Conflit of interest None delared Aepted 20 Marh 2018 Published online April 2018 Permission To reuse this artile or for information about reprints and permissions, ontat permissions@rni.om Abstrat Urinary inontinene is a ommon and usually hidden issue that an affet women of all ages. It is often ignored by the patient beause of their misoneption that inontinene is an inevitable onsequene of ageing and their low expetations of suessful treatment. There are various types of inontinene, with symptoms that an signifiantly affet patients quality of life. This artile aims to enhane nurses understanding of the types of urinary inontinene affeting women, assoiated risk fators and ontinene assessment, as well as the initial investigations and onservative treatments that an be instigated by general nurses. It also disusses some of the advaned treatments offered by speialist servies. The artile emphasises the importane of undertaking a holisti ontinene assessment to ensure appropriate ontinene are is provided, and how tailoring this are to the individual an improve adherene to treatment plans. Author details Ellie Stewart, CNS Urogynaeology, Guy s Hospital, Guy s and St Thomas NHS Foundation Trust, London, England Keywords linial skills, ommunity, ontinene, noturnal enuresis, pelvi floor exerises, primary are, stress inontinene, urge inontinene, urinalysis, urinary disorders, urinary inontinene, urinary trat disorders, urology, women s health Aims and intended learning outomes This artile aims to enhane nurses understanding of the types of urinary inontinene affeting women, assoiated risk fators, ontinene assessment, and initial investigations and onservative treatments that an be instigated by general nurses. After reading this artile and ompleting the time out ativities you should be able to: Desribe the roles of general and speialist nurses in assessing and treating women with urinary inontinene. Reognise the types of urinary inontinene affeting women and the potential effets of symptoms on patients quality of life. Explain the elements of a ontinene assessment and the investigations that should be undertaken for women presenting with urinary inontinene. Outline the onservative treatments for urinary inontinene in women and advie that should be given to patients. Understand when to refer patients to speialist servies and the advaned treatments that these servies may offer. TIME OUT 1 Can you identify the various types of urinary inontinene? Provide a definition for eah type and ompare with the information in this artile. What effets do you think eah type of urinary inontinene might have on a patient s quality of life? Introdution Urinary inontinene is a ommon issue among women of differing ages. Many women do not report their symptoms or seek assistane and support from healthare servies for several years beause of their misoneption that urinary inontinene is an inevitable onsequene of ageing (Rantell 2015) and their low expetations of suessful treatment. They may also feel embarrassed to admit that they are experiening nursingstandard.om

2 ontinene / CPD evidene & pratie symptoms of inontinene and may attempt to manage the ondition alone for as long as possible. Urinary inontinene is more ommon in women than men, experiened by around 10% of all women and more than 20% of women aged over 70 years (Irwin et al 2011). Seeking support and assistane from healthare servies is assoiated with high levels of symptom bother and severity (Irwin et al 2008); the more symptoms someone has and the greater effet these symptoms have on their life, the more likely it is that they will present to healthare servies. There are various types of urinary inontinene, inluding (Haylen et al 2010): Stress inontinene involuntary leakage of urine on effort or exertion, or on sneezing or oughing. Urge inontinene involuntary leakage of urine assoiated with urinary urgeny. Urge inontinene may be assoiated with overative bladder, whih is defined as urinary urgeny, usually aompanied by urinary frequeny and noturia, in the absene of urinary trat infetion (UTI) or other obvious pathology. Mixed inontinene involuntary leakage of urine assoiated with urinary urgeny and exertion, effort, sneezing or oughing. Funtional inontinene where no organi ause for leakage of urine an be identified. This may be a result of ognitive and physial fators. Overflow inontinene involuntary leakage of urine assoiated with suboptimal bladder emptying. Noturnal enuresis loss of urine during sleep. Postural urinary inontinene involuntary loss of urine assoiated with hange of body position. Insensible urinary inontinene where the woman has been unaware of how leakage of urine ourred. Coital inontinene involuntary loss of urine with oitus. This an be further divided into inontinene ourring with penetration or with orgasm. Role of the nurse Continene are is a signifiant aspet of healthare and should be the responsibility of all nurses (Booth 2013). A nurse undertaking a ontinene assessment does not have to be a speialist. As long as the nurse has knowledge of inontinene and its treatment pathways, and reognises when to refer patients to speialist servies, they should be able to perform an assessment. Speialist are does not neessarily need to be take plae in seondary are settings; it an be provided in the ommunity in speialised linis. There are several ontinene are ourses and useful resoures available for nurses, suh as the National Institute for Health and Care Exellene (NICE) (2015) guidelines, Minimum Standards for Continene Care in the UK (Rantell et al 2016) and the International Consultation on Inontinene guidelines (Abrams et al 2017). Nurses should be enouraged to ontat their loal urogynaeology, urology and oloretal nurse speialists, who may be able to provide support and training to develop their skills, for example by observing linis at the hospital, or providing a forum to disuss omplex patients. Nurses should be proative in taking opportunities to ask patients about their ontinene status, for example when they are seen for ervial sreening, mediation review or general hek-up. Early identifiation of any symptoms of urinary inontinene will enable prompt treatment, whih may prevent deterioration that ould result in surgial management, rather than onservative management. Risks fators for urinary inontinene Nurses should be aware of the main risk fators for developing urinary inontinene, whih inlude (NICE 2015, Bardsley 2016): Constipation. Damage to the bladder during surgery affeting the nerves or surrounding tissue. Damage to the pelvi floor during hildbirth. Fluid intake exessive intake of affeinated drinks, insuffiient oral intake, exessive oral fluid intake. Neurologial diseases or onditions affeting the spinal ord or brain, suh as multiple slerosis, Parkinson s disease, stroke. Obesity. Some mediines, for example alpha-adrenergi agonists, antipsyhotis, antidepressants, diuretis and non-steroidal anti-inflammatory drugs. Urinary trat infetion. TIME OUT 2 Consider the risk fators for urinary inontinene. Do any of the patients you are urrently aring for have any of these risk fators? What ations ould you take to address these issues? It is important for nurses to be aware of the risk fators for urinary inontinene and how they might affet the patient s life and their symptoms. For example, those with Parkinson s disease may not be physially able to get to the toilet in time, or may have diffiulty undoing their lothes to enable them to use the toilet, so experiene leakage of urine. Similarly, people with multiple slerosis may have diffiulty emptying their bladder fully, so may need to learn intermittent self-atheterisation to enable them to do so and prevent ompliations suh as UTIs. Continene assessment A thorough and aurate ontinene assessment is essential to enable the appropriate treatment pathway to be ommened for the patient. It is important for the nurse to have an understanding of the types of urinary inontinene affeting women, the onservative treatments available and when to refer the patient to speialist servies (Bardsley 2016). Effetive ommuniation skills are essential for the nurse to obtain the relevant information required to ensure appropriate treatment (Rantell 2015). It is vital that the nurse uses language that is easy to understand and avoids using tehnial, medial terminology. For example, the nurse should avoid using words suh as noturia or urge inontinene when questioning the patient. Instead, they should use words and phrases that are easily understood, suh as How many times do you get up to go nursingstandard.om

3 to the toilet at night? or Do you leak on the way to the toilet if you don t make it in time?. It may also be neessary for the nurse to tailor the way they ask questions and the language they use, depending on the age and level of understanding of the patient. The nurse should use open questions to enourage the patient to provide useful information (Bardsley 2014), rather than losed questions, whih are easy to answer but provide little information. It is important for the nurse to onsider their own body language during the assessment. Smiling enourages the patient to feel relaxed, as does an open posture and nodding in response to the patient s omments. The nurse should be empatheti and sensitive. It is important to remember that this may be the first time that the patient has disussed their inontinene. They may be feeling worried or embarrassed, so the nurse should attempt to put them at ease and enable them to talk about their issues openly. The nurse should also note any onerning body language, suh as a lak of eye ontat, and have an understanding of when it is appropriate to question further, when to stop questioning and when there are safeguarding onerns. The nurse will develop these skills with experiene, and with eduation and support from experiened olleagues. Effetive interpersonal skills will enable a trusting therapeuti relationship to be developed between the patient and nurse (Rantell 2013), whih will inrease the individual s adherene to treatment and support symptom improvement. Questionnaires are often used during the assessment to provide a baseline understanding of how the patient views their symptoms and how their quality of life is affeted (Robinson et al 2007). They an be ompleted again at the end of treatment to evaluate any improvements in symptoms and quality of life. Questionnaires ommonly used when assessing urinary inontinene in women are the King s Health Questionnaire (Kelleher et al 1997), International Consultation on Inontinene Questionnaire Overative Bladder (ICIQ-OAB) (Abrams et al 2006), Urinary Inontinene Quality of Life Sale (I-QOL) (Chen et al 2014) and International Consultation on Inontinene Questionnaire (ICIQ) (Abrams et al 2006). If questionnaires are used in ontinene assessment, it is important to onsider how easy they are for the patient to omplete and sore the results (Hewison et al 2014). Important areas to disuss during a ontinene assessment Identifying whih issue is the most signifiant for the patient Different symptoms will affet different people in different ways. It is important for the nurse to asertain whih issue is the most signifiant for the patient. For example, the patient may report that it may not be going to the toilet one every hour during the day that bothers her the most, but that she is up five times per night to use the toilet, so she is not ahieving adequate sleep for her to do her job safely. If the patient s most signifiant issue an be identified and addressed, she may be inreasingly likely to adhere to the treatment plan. Quality of life Often, urinary inontinene signifiantly affets the patient s quality of life, for example as a result of not being able to wear white jeans in the summer in ase of leaking and/or having to wear dark trousers to work or arry a hange of underwear at all times. Patients may beome depressed, experiene sexual dysfuntion, loss of respet or self-esteem, and inur additional expenses related to managing their inontinene (Yates 2017). Obstetri and gynaeologial history The number of births, type of delivery, tears and whether the deliveries were instrumented will affet the pelvi floor (Herbert 2009) and onsequently symptoms of urinary inontinene. Women often report suh symptoms following a hysteretomy; therefore, it is important to asertain what gynaeologial surgery the patient has had to determine the ause. Mediation review A review of the patient s urrent mediines is a vital aspet of Key points Urinary inontinene is more ommon in women than men, experiened by around 10% of all women and more than 20% of women aged over 70 years (Irwin et al 2011) Different symptoms will affet different people in different ways. It is important for the nurse to asertain whih issue is the most signifiant for the patient Often, urinary inontinene signifiantly affets the patient s quality of life. Patients may beome depressed, experiene sexual dysfuntion, or loss of respet or self-esteem, and inur additional expenses related to managing their inontinene (Yates 2017) Mediines an be presribed if lifestyle hanges are not effetive in improving the patient s symptoms. Antiholinergis are the most ommonly used type of mediines to treat overative bladder symptoms of urinary urgeny, urinary frequeny, urge inontinene and noturia a ontinene assessment, sine several mediines an ause or exaerbate urinary inontinene. It is important to identify if the patient is taking any of these mediines (Harris 2007). Table 1 details some of the ommon drugs that may affet ontinene. Investigations There are several basi investigations and tests that the nurse should perform as part of the initial ontinene assessment (NICE 2015). Urinalysis Urinalysis should be undertaken for all women undergoing a ontinene assessment. It is a reliable indiator of a UTI (Davis and Rantell 2017), as well as any haematuria, whih is a red flag indiation for referral to urology servies. Any infetion should be treated and the urinalysis repeated to assess if symptoms have improved (Ostle 2016). Overative bladder symptoms are similar to the symptoms experiened with a UTI, so infetion should be exluded before initiating treatment for overative bladder. nursingstandard.om

4 ontinene / CPD evidene & pratie Post-void residual test A post-void residual test will demonstrate if the patient is emptying their bladder fully. Inomplete voiding an lead to UTIs (Davis and Rantell 2017) and an indiate other issues, suh as onstipation. A post-void residual test an be performed with an in and out atheter (a atheter that is inserted into the bladder and removed one the residual has been drained) or bladder sanner (Bardsley 2016). Constipation, large fibroids, pregnany, vaginal prolapse and previous ontinene surgery an ause voiding diffiulties, whih may lead to reurrent UTIs, urinary frequeny and urinary urgeny. Double voiding is a simple tehnique that the patient an be taught, whih redues the feeling of urine being left inside the bladder. This involves asking the patient to stand up and sit down, rok forwards and bakwards and squeeze the pelvi floor after voiding, to attempt to get rid of TABLE 1. Drugs that may affet ontinene Drug type Alpha-adrenergi agonists, for example methyldopa Antipsyhotis, for example haloperidol, hlorpromazine hydrohloride Antidepressants, for example amitriptyline hydrohloride, imipramine hydrohloride Diuretis, for example bendroflumethiazide Calium hannel blokers, for example amlodipine, nifedipine, diltiazem hydrohloride Angiotensin onverting enzyme inhibitors (ACE inhibitors), for example enalapril maleate, aptopril, lisinopril, ramipril Opiates, for example odeine phosphate, morphine, oxyodone hydrohloride Antiholinergis, for example oxybutynin hydrohloride, tolterodine tartrate, solifenain suinate Non-steroidal anti-inflammatory drugs, for example dilofena, ibuprofen, naproxen (Adapted from British National Formulary 2017) any urine left in the bladder after the initial void. Bladder diary A bladder diary is a useful tool, sine it an provide information about the type and volume of fluids onsumed by the patient and the frequeny of their miturition (Nazarko 2015), as well as the volumes passed, whih will be an indiator of bladder volume. NICE (2015) guidelines reommend that the patient should omplete a bladder diary for three days to provide information about their bladder habits. However, bladder diaries are rarely ompleted fully or at all. They an be hallenging to omplete and the patient needs to understand what they need to do, so these diaries may not be suitable for people with learning diffiulties or memory loss (Prie 2011). Vaginal examination The vagina should be examined for anterior and posterior wall prolapse and uterine prolapse, skin Effet on ontinene May ontrat the bladder nek, ausing retention and overflow urinary inontinene May ause stress inontinene Can ause urinary retention and overflow urinary inontinene May inrease urinary frequeny, urinary urgeny, urge inontinene Can derease smooth musle ontratility in the bladder, ausing urinary retention and onstipation Bloks the angiotensin reeptors in the bladder, whih dereases detrusor ontratility and urethral tone, whih an improve urge inontinene but inrease stress inontinene May ause onstipation and urinary retention by inhibiting bladder ontrations, sedation, faeal impation and delirium Can ause urinary retention post-void dribbling, straining, hesitany and overflow urinary inontinene May ause urinary retention in older adults ondition, vaginal atrophy and any inontinene, whih an be assessed with a ough test (Rantell 2013). A ough test involves asking the patient to ough while lying down and observing if there is any leakage of urine. A digital vaginal examination an also be performed by an appropriately trained nurse to assess the patient s pelvi floor funtion and strength. Before undertaking a digital vaginal examination or other invasive investigations, the nurse must ask the patient if they wish for a haperone to be present. Retal examination The nurse an observe the anal area for skin tags, retal prolapse and skin ondition (Nazarko 2015). Digital retal examination an be used to diagnose faeal loading (a large volume of stool in the retum), faeal impation (a solid, immobile lump of faees in the retum, usually as a result of hroni onstipation) and squeeze pressure (pressure produed when the anus is squeezing to avoid defaeating). Sine the retum is lose in proximity to the bladder, if it is full, this may inrease voiding diffiulties, urinary frequeny and urinary urgeny. Red flag signs and symptoms Referral to speialist servies should be initiated immediately if any of the red flag signs and symptoms listed in Box 1 are identified during the assessment (NICE 2015, Rantell et al 2016). If aner is suspeted, the patient must be urgently referred on a two-week wait pathway. Speial populations Care should be taken when assessing older adults, people with ognitive impairment, people with redued mobility and women who are pregnant, beause the standard assessment and treatment pathways might not be appropriate for them. For example, in older adults, inontinene is strongly assoiated with dementia, redued physial funtioning, onstipation and UTIs (Byles 2009). Furthermore, Morris and Wagg (2007) stated that urinary frequeny, urinary urgeny and noturia inrease the risk of falling in older adults, whih leads to an inrease in fratures and admissions to hospital and nursing homes. nursingstandard.om

5 An assessment tailored to older patients will ensure that mobility issues, mediines use, and their soial networks and soial are, are disussed in detail and that realisti treatment options are suggested. For example, it may be more appropriate to refer an older patient for an oupational therapy assessment for a ommode to use at night-time, rather than them having to attempt to get to the toilet in time, whih inreases the risk of falling. Conservative treatments Conservative treatments are available for all types of urinary inontinene (Table 2) and an be instigated easily by general nurses and in primary are. It is essential that the progress of patients undertaking these treatments is reviewed regularly, and that they are given positive feedbak to maintain adherene to the treatment plan. If onservative treatments are not effetive and improvements are not identified, the patient an be referred to speialist servies for further assessment and advaned treatments. Pelvi floor exerises NICE (2015) guidelines reommend that supervised pelvi floor exerises should be undertaken for at least three months. These exerises are an effetive way of strengthening the pelvi floor musles and improving symptoms of inontinene. NICE (2015) guidelines suggest that women should perform at least eight ontrations three times per day to ahieve a notieable improvement in symptoms. Women whose symptoms do not improve following a ourse of pelvi floor exerises should be referred to a urogynaeologist for further management options (Ostle 2016). Weighted vaginal ones an be used instead of, or to augment, pelvi floor exerises; however, the literature indiates there is no differene in the effetiveness of vaginal ones ompared with pelvi floor exerises (Haslam 2008). Mobile phone apps are available that are designed to motivate and remind women to undertake their pelvi floor exerises regularly. Whitehouse (2012) suggested that women who are motivated and reeive regular feedbak are inreasingly likely to ontinue with their exerise programme and notie an improvement in their symptoms and a redution in inontinene episodes. A devie known as an Elvie trainer an be inserted into the vagina; when squeezed, this ativates a biofeedbak mehanism so that women an monitor how hard they are squeezing their musles, and how long for, on their mobile phone. Pelvi floor exerise programmes are also available online. Bladder retraining Bladder retraining aims to inrease the time in between trips to the toilet by enouraging the patient to hold on when they need to go, whether this is for 30 seonds or ten minutes. This aims to improve the patient s ontrol of their bladder (Nazarko 2015). Over time, this an redue symptoms of urinary frequeny, urinary urgeny and noturia. Fluid advie Guidelines reommend that patients redue their affeine intake to improve overative bladder symptoms (NICE 2015, Syan and Bruker 2016). Citrus drinks, fizzy drinks and alohol are also known bladder irritants (Stewart 2011). Patients should be advised to avoid or redue these to see if their symptoms improve. A fluid intake of around litres per day is reommended. If the patient s fluid intake is insuffiient, their urine an be strong and irritate the bladder, ausing urinary frequeny and urinary urgeny, while if their fluid intake signifiantly exeeds the reommended amount, they may experiene urinary frequeny. Modifying fluid intake an improve these symptoms (Ostle 2016). If a patient experienes noturia, they should be advised to restrit their BOX 1. Red flag signs and symptoms requiring referral to speialist servies Visible haematuria (urology) Mirosopi haematuria in women aged over 50 years (urology) Voiding diffiulties (urology) Persistent bladder or urethral pain (urology) Suspeted neurologial disease (urology) Complex symptoms suh as a ombination of storage and voiding symptoms (urology) Reurrent urinary trat infetions (urology or urogynaeology) Previous pelvi aner or suspeted malignany (urology or urogynaeology) Previous pelvi aner surgery or radiation therapy (urology or urogynaeology, depending on the type of surgery performed) Benign pelvi masses (urogynaeology) Suspeted urogenital fistula (urology or urogynaeology) Symptomati urogenital prolapse (urogynaeology) Failure of onservative management (urogynaeology) Previous ontinene surgery (whihever servie undertook the previous surgery) Assoiated faeal inontinene (oloretal) (Adapted from National Institute for Health and Care Exellene 2015) TABLE 2. Conservative treatments for urinary inontinene Issue Stress inontinene Funtional inontinene Mixed inontinene Overative bladder Voiding diffiulties Conservative treatment Pelvi floor exerises, vaginal ones, Squeezy NHS Pelvi Floor mobile phone app, eletrial stimulation of the pelvi floor musles, Elvie trainer Oupational therapy referral for ommodes or aids to assist with toileting, lothes with elastiated waists or Velro so they an be removed quikly for toileting Pelvi floor exerises, bladder retraining, fluid advie, onstipation management, antiholinergis Bladder retraining, pelvi floor exerises, fluid advie, antiholinergis Intermittent self-atheterisation, double voiding, onstipation prevention advie nursingstandard.om

6 ontinene / CPD evidene & pratie fluid intake during the evening to redue these episodes. Timed or prompted voiding Patients with dementia may benefit from regular verbal reminders to establish a toileting routine and to assist them in reognising the signs of needing to go to the toilet (Prie 2011). Morgan et al (2008) suggested that a personalised toileting programme (timed voiding) is effetive in pre-empting the need to go to the toilet. However, this type of intervention is labour intensive. Timed voiding ensures that the bladder is emptied at regular intervals, rather than only when the patient feels the urge to void. This assists in preventing the bladder from overfilling and sending urgent messages for it to be emptied. Prompted voiding aims to improve bladder ontrol using verbal prompts, reminders and positive reinforement (Eustie et al 2000). Weight loss Obesity is a signifiant modifiable and reversible risk fator for stress inontinene (Faiena et al 2015). Subak et al (2009) suggested that moderate weight loss may derease episodes of urinary inontinene. The nurse should support women in their attempt to lose weight and inform them of the general health benefits as well as the potential redution in their inontinene episodes. Mediines Mediines an be presribed if lifestyle hanges are not effetive in improving the patient s symptoms. Antiholinergis are the most ommonly used type of mediines to treat overative bladder symptoms of urinary urgeny, urinary frequeny, urge inontinene and noturia. NICE (2015) guidelines suggest that oxybutynin hydrohloride, tolterodine tartrate or darifenain should be offered as a first-line treatment, or a lyrinel path for those unable to tolerate oral mediines. The most ommon side effets of antiholinergis are onstipation, blurred vision and dry mouth (Robinson and Cardozo 2012). These potential side effets should be onsidered when seleting the appropriate mediine. Vaginal pessaries Vaginal prolapse is often treated with pelvi floor exerises and/or vaginal pessaries. There are various types of silione and plasti vaginal pessaries available, whih provide support and redue the feeling of heaviness, whih is one of the main symptoms of vaginal prolapse. Anantawat et al (2016) demonstrated that the use of a vaginal pessary for six months improves vaginal symptoms and quality of life in women with prolapse. Ring pessaries are the most ommonly used type of pessary. They are inserted into the vagina and should be hanged every six months. They are a useful management option for women of hildbearing age with a vaginal prolapse who wish to have hildren, or those who do not want to onsider surgial management or for whom surgial management is not an option (Storey et al 2009). Pessaries an be inserted and managed by non-speialist nurses who have ompleted appropriate training, but they are often managed by speialist nurses. Training in the use of pessaries an be reeived from the urogynaeology team. Nurses should be aware to observe for vaginal bleeding in those who have a pessary. If this ours, the patient should be referred to the onology team for assessment of the endometrial thikness and investigation of possible endometrial aner. Silione pessaries are easy to insert and remove, and last for up to five years. They an be used by younger pre-menopausal women who do not require the ondition of their vagina to be heked for uleration and bleeding every six months. Patients an be shown how to insert and remove their pessaries as and when they want to (Kearney and Brown 2014), but should be advised to remove them to lean them at least one every six months. Some women remove them to have sexual interourse, while others use them for extra support and symptom relief, for example if they know they will be spending the day walking or standing on their feet for long periods. Others use them and do not remove them. Patients with pessaries who are pre-menopausal do not require fae-to-fae lini follow-up appointments; they an manage their pessaries independently with a telephone follow-up appointment every six months. Intravaginal oestrogens Vaginal atrophy, also known as atrophi vaginitis, ours when the vaginal tissues lak oestrogen and as a result an beome dry, thin and may bleed (Domoney 2014). It an lead to dereased strength in pelvi floor musles and urge inontinene (Bardsley 2014). Vaginal atrophy is ommonly experiened by post-menopausal women (MaBride et al 2010), who frequently report that their vagina feels dry and unomfortable, and that sexual interourse is not as pleasurable (Domoney 2014). Furthermore, vaginal atrophy is the most ommon ause of vaginal bleeding in post-menopausal women with a vaginal pessary. If vaginal atrophy ours, the movement of a pessary in the vagina an ause uleration and bleeding. Intravaginal oestrogens may be benefiial in maintaining normal struture and funtion of the urogenital tissue. However, NICE (2015) guidelines reommend that systemi hormone replaement therapy is not offered to treat urinary inontinene, but intravaginal oestrogens an be onsidered to treat overative bladder symptoms in post-menopausal women with vaginal atrophy. Women with vaginal atrophy and a vaginal pessary are often started on a low dose of intravaginal oestrogen (Bulhandani et al 2015). TIME OUT 3 Conservative treatments are available for all types of urinary inontinene in women. Reflet on what these are and how experiened and onfident you are in providing these treatments. Whih do you need support and pratie in to develop your skills, and how would you ahieve this? Urodynami investigations and advaned treatments Many patients who undertake onservative treatments for inontinene do not experiene signifiant improvement in their symptoms or quality of life. These women should be referred to the urogynaeology servie for further assessment and treatment. nursingstandard.om

7 Urodynami investigations are reommended to diagnose the type of inontinene (Thüroff et al 2011, NICE 2015) and to determine if surgial management is an option (Syan and Bruker 2016). They are often performed by a speialist nurse in the hospital setting. Botulinum toxin (Botox) injetions are available for those who have tried two different types of antiholinergis and not notied any signifiant symptom relief. It is important that a speialist nurse teahes the patient intermittent selfatheterisation before the injetions, beause there is a risk of retention or inomplete voiding post-operatively. Perutaneous tibial nerve stimulation and saral nerve stimulation an also be offered for those with overative bladder symptoms, where onservative treatments have been unsuessful (Syan and Bruker 2016). Patients requiring these advaned treatments must first undergo urodynami investigations and be disussed in multidisiplinary team meetings with urologists and liniians with an interest in pelvi floor dysfuntion (NICE 2015). TIME OUT 4 A female patient who is experiening urinary inontinene asks you what advaned treatments may be offered by a speialist urogynaeology servie. How would you explain these treatments to them? You may wish to disuss this with a olleague Conlusion It is often several years before a woman with urinary inontinene presents to healthare servies for treatment and support. Nurses are well-plaed to identify patients who are experiening inontinene and to provide initial investigations and treatments. Initial onservative treatments an be provided following a thorough ontinene assessment by a suitably skilled nurse. Adherene to linial guidelines enables a strutured assessment and treatment pathway to be ommened, with appropriate referral to speialist servies if required. TIME OUT 5 Consider how the assessment and management of inontinene in women relates to The Code: Professional Standards of Pratie and Behaviour for Nurses and Midwives (Nursing and Midwifery Counil 2015) or, for non-uk readers, the requirements of your regulatory body TIME OUT 6 Now that you have ompleted the artile, reflet on your pratie in this area and onsider writing a refletive aount: rni.om/refletive-aount Referenes Abrams P, Avery K, Gardener N et al (2006) The International Consultation on Inontinene Modular Questionnaire: Journal of Urology. 175, 3, Abrams P, Cardozo L, Wagg A et al (Eds) (2017) Inontinene: 6 th International Consultation on Inontinene. Tokyo, September International Continene Soiety, Bristol. Anantawat T, Manonai J, Wattanayingharoenhai R et al (2016) Impat of a vaginal pessary on the quality of life in women with pelvi organ prolapse. Asian Biomediine. 10, 3, Bardsley A (2014) Promoting urinary ontinene in older women. Nursing Standard. 29, 8, Bardsley A (2016) An overview of urinary inontinene. Pratie Nursing. 27, 11, Booth J (2013) Continene are is every nurse s business. Nursing Times. 109, 17-18, British National Formulary (2017) British National Formulary. No. 74. BMJ Group and the Royal Pharmaeutial Soiety of Great Britain, London. Bulhandani S, Toozs-Hobson P, Verghese T et al (2015) Does vaginal estrogen treatment with support pessaries in vaginal prolapse redue ompliations? Post Reprodutive Health. 21, 4, Byles J (2009) Exploring key points from a longitudinal study of older women on urinary inontinene. Nursing Times. 105, 40, Chen G, Tan JT, Ng K et al (2014) Mapping of inontinene quality of life (I-QOL) sores to assessment of quality of life 8D (AQoL-8D) utilities in patients with idiopathi overative bladder. Health and Quality of Life Outomes. 12, 133. doi: / s Davis C, Rantell A (2017) Lower urinary trat infetions in women. British Journal of Nursing. 26, 9, S12-S19. Domoney C (2014) Treatment of vaginal atrophy. Women s Health. 10, 2, Eustie S, Roe B, Paterson J (2000) Prompted voiding for the management of urinary inontinene in adults. Cohrane Database of Systemati Reviews. Issue 2. CD Faiena I, Patel N, Parihar JS et al (2015) Conservative management of urinary inontinene in women. Reviews in Urology. 17, 3, Harris A (2007) Assessing urinary inontinene in women. Nursing Times. 103, 26, Haslam J (2008) Vaginal ones in stress inontinene treatment. Nursing Times. 104, 5, Haylen BT, de Ridder D, Freeman RM et al (2010) An International Urogyneologial Assoiation (IUGA)/ International Continene Soiety (ICS) joint report on the terminology for female pelvi floor dysfuntion. International Urogyneology Journal. 21, 1, Herbert J (2009) Pregnany and hildbirth: the effet on pelvi floor musles. Nursing Times. 105, 7, Hewison A, MCaughan D, Watt I (2014) An evaluative review of questionnaires reommended for the assessment of quality of life and symptom severity in women with urinary inontinene. Journal of Clinial Nursing. 23, 21-22, doi: / jon Irwin DE, Abrams P, Mislom I et al (2008) Understanding the elements of overative bladder: questions raised by the EPIC study. BJU International. 101, 11, Irwin DE, Kopp ZS, Agatep B et al (2011) Worldwide prevalene estimates of lower urinary trat symptoms, overative bladder, urinary inontinene and bladder outlet obstrution. BJU International. 108, 7, Kearney R, Brown C (2014) Self-management of vaginal pessaries for pelvi organ prolapse. BMJ Quality Improvement Reports. 3, 1. doi: / bmjquality.u w2533. Kelleher CJ, Cardozo LD, Khullar V et al (1997) A new questionnaire to assess the quality of life of urinary inontinent women. British Journal of Obstetris and Gynaeology. 104, 12, MaBride MB, Rhodes DJ, Shuster LT (2010) Vulvovaginal Atrophy. Mayo Clini Proeedings. 85, 1, Morgan C, Endozoa N, Paradiso C et al (2008) Enhaned toileting program dereases inontinene in long term are. Joint Commission Journal on Quality and Patient Safety. 34, 4, Morris V, Wagg A (2007) Lower urinary trat symptoms, inontinene and falls in elderly people: time for an intervention study. International Journal of Clinial Pratie. 61, 2, National Institute for Health and Care Exellene (2015) Urinary Inontinene in Women: Management. Clinial guideline No NICE, London. Nazarko L (2015) Person-entred are of women with urinary inontinene. Nurse Presribing. 13, 6, Nursing and Midwifery Counil (2015) The Code: Professional Standards of Pratie and Behaviour for Nurses and Midwives. NMC, London. Ostle Z (2016) Assessment, diagnosis and treatment of urinary inontinene in women. British Journal of Nursing. 25, 2, Prie H (2011) Inontinene in patients with dementia. British Journal of Nursing. 20, 12, Rantell A (2013) Assessment and diagnosis of overative bladder in women. Nursing Standard. 27, 52, Rantell A (2015) Understanding urinary inontinene in women. Pratie Nursing. 26, 6, Rantell A, Dolan L, Bonner L et al (2016) Minimum standards for ontinene are in the UK. Neurourology and Urodynamis. 35, 3, doi: /nau Robinson D, Cardozo L (2012) Antimusarini drugs to treat overative bladder. BMJ. 344, e2130. doi: /bmj.e2130. Robinson D, Anders K, Cardozo L et al (2007) Outome measures in urogynaeology: the liniians perspetive. International Urogyneology Journal. 18, 3, Stewart E (2011) Presribing antimusarinis for women with an overative bladder. Nurse Presribing. 9, 2, Storey S, Aston M, Prie S et al (2009) Women s experienes with vaginal pessary use. JAN. 65, 11, Subak LL, Wing R, Smith West DS et al (2009) Weight loss to treat urinary inontinene in overweight and obese women. New England Journal of Mediine. 360, 5, Syan R, Bruker BM (2016) Guideline of guidelines: urinary inontinene. British Journal of Urology International. 117, 1, Thüroff JW, Abrams P, Andersson KE et al (2011) EAU guidelines on urinary inontinene. European Urology. 59, 3, doi: /j.eururo Whitehouse T (2012) Patient motivation in managing stress urinary inontinene. Nursing Times. 108, 18-19, 20. Yates A (2017) Inontinene and assoiated ompliations: is it avoidable? Nurse Presribing. 15, 6, nursingstandard.om

8 ontinene / multiple-hoie quiz Urinary inontinene in women TEST YOUR KNOWLEDGE BY COMPLETING THIS MULTIPLE-CHOICE QUIZ 1. Whih statement is false? a) Urinary inontinene is more ommon in women than men b) Urinary inontinene is an inevitable onsequene of ageing ) Patients are often embarrassed to admit that they are experiening symptoms of inontinene d) Seeking support and assistane from healthare servies for inontinene is assoiated with high levels of symptom bother and severity 2. Whih of the following types of urinary inontinene is defined as the involuntary leakage of urine assoiated with suboptimal bladder emptying? a) Overflow inontinene b) Stress urinary inontinene ) Noturnal enuresis d) Coital inontinene 3. Whih of these is not a risk fator for urinary inontinene? a) Obesity b) Urinary trat infetion ) Hypertension d) Constipation 4. During a ontinene assessment, the nurse should: a) Identify whih issue is the most signifiant for the patient b) Review the patient s urrent mediines ) Asertain what gynaeologial surgery the patient has had, if any, to assist in determining the ause of their inontinene d) All of the above 5. Whih type of mediines may affet ontinene by dereasing smooth musle ontratility in the bladder, ausing urinary retention and onstipation? a) Antidepressants b) Calium hannel blokers ) Diuretis d) Antipsyhotis 6. One disadvantage of using a bladder diary when assessing a patient s bladder habits is: a) They are expensive to omplete b) They do not provide any information about the type and volume of fluids that the patient onsumes ) They an be hallenging for patients to omplete, partiularly for those with learning diffiulties or memory loss d) They annot be used to determine the frequeny of the patient s miturition 7. A patient should be referred to a urology servie if they have whih of the following red flag signs or symptoms? a) Benign pelvi masses b) Visible haematuria ) Assoiated faeal inontinene d) Symptomati urogenital prolapse 8. What is the most ommonly used type of mediine to treat overative bladder symptoms? a) Antiholinergis b) Opiates ) Beta blokers d) Anxiolytis 9. Vaginal pessaries an be used to: a) Assist patients when undertaking pelvi floor exerises b) Enourage patients to empty their bladder at regular intervals, rather than only when they feel the urge to void ) Provide support and redue the feeling of heaviness that women with vaginal prolapse may experiene d) Treat vaginal atrophy and bleeding 10. Whih of the following is an advaned treatment for inontinene that may be offered in speialist servies? a) Perutaneous tibial nerve stimulation b) Saral nerve stimulation ) Botulinum toxin (Botox) injetions d) All of the above How to omplete this quiz This multiple-hoie quiz will help you to test your knowledge. It omprises ten questions that are broadly linked to the CPD artile. There is one orret answer to eah question. You an test your subjet knowledge by attempting the questions before reading the artile, and then go bak over them to see if you would answer any differently. You might like to read the artile before trying the questions. Subsribers making use of their RCNi Portfolio an omplete this and other quizzes online and save the result automatially. Alternatively, you an ut out this page and add it to your professional portfolio. Don t forget to reord the amount of time taken to omplete it. Further multiple-hoie quizzes are available at rni.om/pd/test-yourknowledge This multiple-hoie quiz was ompiled by Alex Bainbridge The answers to this multiple hoie quiz are: 1. b 2. a d 5. b b 8. a d This ativity has taken me minutes/hours to omplete. Now that I have read this artile and ompleted this quiz, I think my knowledge is: Exellent Good Satisfatory Unsatisfatory Poor As a result of this I intend to: nursingstandard.om