Managing Female Urinary Incontinence Within Primary Care Angela Patterson Lead Clinical Nurse Specialist in Bladder and Bowel Dysfunction. South Eastern HSCT
Background More than 14 million in the UK affected by urinary incontinence 6.5 million affected by Bowel dysfunction (Buckley and Lapitan 2009) 900,00 children and young adults affected (NICE 2010).
Background UI is more prevalent than Asthma, Epilepsy or Dementia (APPG Continence Care 2013) Can have devastating consequences Costs to the NHS 353.6million (1998)
Background More cost effective to treat than contain 70% can be cured - (Roe, Moore 2001) Conservative treatments should be first line option (NICE and SIGN guidelines)
Consequences For the Patient Depression, isolation, shame, loss of confidence. Skin damage Increased UTI Rate UI identified as the second most common reason for admission to institutionalised care after Dementia
Consequences Continued 50% of falls in Hospital settings are linked to Urinary Incontinence Cost to Health Service in NI alone is almost 5 Million Pounds annually. 10% of the population is expected to experience UI at some point in their lives. Affects all age groups.
Sexual Dysfunction
Sexual Dysfunction Dyspareunia Fear of incontinence coping mechanisms Feeling unfeminine and unattractive Reduced libido Insomnia leading to fatigue Up to 50% of females with incontinence may report some degree of sexual dysfunction Leakage on sexual intercourse can be attributed to either stress incontinence or an overactive bladder Under asked, so probably under reported
Sexual Dysfunction Women with UI have lower overall sexual function, frequency of intercourse, more problems with communication, and avoid sexual activity. (Beker et al 2010) Detrusor overactivity has more impact upon sexual function than stress incontinence (Yip et al 2003) Impact of impaired sexual dysfunction: Affects 43% women 22% men Worried about coital incontinence 49% women 6% men Consider it a problem 84% women and 35% men. Female reluctance to be sexually active can also affect the partner.
Why is good continence care important? Francis Report (2013) 76% of the verbal complaints were related to continence care emotive topic Incontinence is arguably the biggest threat to an individual s dignity Where continence care is reported to be poor it is an indicator that overall care will be poor (Booth 2013)
Assessment Tools There are many assessment tools available none are perfect You are in a unique position to ask the vital question do you experience problems with your bladder or bowels? Have the conversation You may be the only person the patient has confided in.
My Role
Lead a team who provide specialist treatment to patients with bladder and bowel dysfunction across SET. 82% success rate Save Trust approx 200K annually by treating rather containing. Referrals come from wide range of sources across the Trust and outside Trust Aim is to resolve incontinence where at all possible Not to provide containment products
Bladder Dysfunction
Stress Incontinence Name misleading Occurs when abdominal pressure greater than the closure pressure of the urethral sphincter / bladder neck or weakness in PF May not occur on cough, laugh or sneeze No urgent desire to void Patient has normal bladder capacities and patterns Symptoms often worse pre-menstrually Volumes are small, may be mistaken for continuous leakage, or patient may not be aware of when it occurs Often associated with childbirth, but not exclusively so Can affect young girls and men also
Questions to ask to Assist with Nursing Diagnosis Voiding patterns and bladder capacities will be normal F and V chart or voiding diary can be very useful Small volumes subjective When does it occur? Not preceded by urgency Is it worse before period? Is there PF weakness? PMD? Does leakage occur during mechanics of sexual intercourse?
Treatment Options PF Rehabilitation: PFE Biofeedback Electro stimulation Pessaries Urethral devices Intravaginal devices Surgical intervention following UDS tape procedure Need to settle all other urinary symptoms before onward referral
Overactive Bladder (OAB) Patients will void frequently throughout the day and night Cannot defer the need to void Urge incontinence Pass small amounts of urine frequently As day time symptoms worsen, nocturia will worsen Has safety implications for elderly Stress and cold weather will worsen symptoms Prevalence increases with age Affects adult men and women, and children Patients with neurogenic conditions will have a high prevalence Need to screen for incomplete emptying, stones and BCC. Coping mechanisms
Questions To Ask That Will Aid Nursing Diagnosis F and V chart will show patient passes small amounts frequently Can they suppress urge to void? Do they leak en-route to bathroom? Is leakage precipitated by an urgent need to void? Are symptoms worse at times of stress or in cold weather? Does the sound of running water cause urgency? Are they disturbed a lot at night? Do they drink a lot of tea and coffee? Are they prone to UTIs? Do they rely on coping mechanisms? Do they leak urine during climax
Treatment Options Fluid intake caffeine, energy drinks, cranberry juice F and V chart or voiding diary useful Exclude UTI. Consider local oestrogen if atrophic. Exclude incomplete emptying male patients prostate screening. Bladder retraining (BRT) Fluid manipulation
Treatment Options Anti-cholinergics / antimuscarinics Surgery will often worsen symptoms permanently Often symptoms can co-exist with stress incontinence mixed picture Treat constipation Fast track to urology if any red flags present
Incomplete Emptying Patients will often present with urgency and frequency, and nocturia Sometimes they will appear to have normal voiding patterns, or, can go for excessive periods of time in between voids Often have recurrent UTIs High prevalence with neurogenic patients, cystocele with kinked urethra, or enlarged prostate Exacerbated by constipation and faecal impaction Can be caused by allowing bladder to overfill poor awareness of bladder filling or deferring need to void.
Questions that will aid nursing diagnosis Is the stream poor? Does the patient feel their bladder is not empty after a void? Do they have to return to bathroom a short time after last void? Do they have a neurogenic condition, cystocele or enlarged prostate? Do they have poor awareness of bladder filling? Do they void very infrequently during the day? Are they prone to UTIs? Are they troubled with constipation?
Treatment Options Resolve constipation need to be pro-active rather than reactive If cystocele present consider pessary may worsen symptoms, and need for post menopausal women to be commenced on local oestrogen first Series of post void scans to confirm diagnosis Double voiding Timed Voiding Male patients medication for enlarged prostate / surgical assessment Be aware of blinkered diagnosis Intermittent self catheterisation (ISC) Fast track through to urology if any red flags present
Specialist Treatment Options
Electro-Stimulation Similar action to Tens Useful biofeedback properties Used for patients with poor pelvic floor strength or de-nervation Can be used for stress incontinence, pelvic floor weakness, urinary urgency, bladder pain. Patients use the device at home with unit on loan (probe single patient use) Lots of contraindications to use so patients need to be screened Not a substitute for PFE!
Urethral Devices Commercially available from about two years ago Silicone body with introducer, and inert oil within body of device Designed to occlude urethra Patients need to be sized, and stress tested Patients also need to be able to insert and remove independently Ideal for short periods of time, on high impact Not a treatment option but a practical solution Available on script.
Intra-Vaginal Devices / Pessaries Lots of devices available patients should be assessed before commencing treatment Most intra- vaginal devices are designed to strengthen the pelvic floor through resistance training Most are not individualised to the patient s needs Not a quick fix solution One person use devices so not supplied by our department Peri-ometer different mechanism usual visual guide Vaginal cones not a quick fix Need to improve pelvic floor strength before starting Tampons with caution - TSS
Intermittent Self Catheterisation (ISC) Before commencing ISC, need to determine the actual need to proceed. Several ultra sound scans performed to determine PVS Patients need to be willing and motivated to learn Patients void naturally and catheter only introduced to drain what the bladder cannot empty for itself Volumes equal to or less than 100mls - questionable need Socially clean procedure for the patient Patient preference Available on script
Pessaries Traditionally used for prolapse Now have multiple uses Available in many sizes and shapes Silicone light, flexible and comfortable Type chosen dictated by bladder dysfunction and if prolapse present. Ideally Oestrogen required for post menopausal women before insertion or silk or replens.
Pre-Tibial Nerve Stimulation (PTNS) Superficial way of stimulating the sacral nerve complex Acupuncture needle inserted percutaneously just above and medial to the ankle Attached to low voltage stimulator seeking a motor or sensory response Can be used for urinary urgency and faecal urgency More uses are being researched Expensive option compared to other conservative treatments Less expensive than Botox and neuro-modulation / implantable devices not a first line option Patients attend for 12 weekly sessions at 30 mins May require top up sessions
In Conclusion The affects of UI can be devastating for the patient of all age groups There is an extremely high prevalence of urinary dysfunction and incontinence most of which is hidden.
Many treatments available with impressive results Basic interventions such as fluid review, treating constipation, treating UTI, and challenging coping mechanisms can have a significant positive impact.
Take Home Message For Today The most important thing you can do is to ask the question / have the conversation Inform patient that they don t need to suffer in silence many treatment options available Get to know you local specialist team and how you can refer patients
This has only been an introduction into how UI can be managed in Primary Care. Further courses available at UUJ and CEC Each Trust has a Specialist Continence Team make contact and attend a clinic
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