Incontinence and stroke

Wendy BrooksStroke Nurse Consultant

Epsom and St Helier University Hospitals NHS Trust

• Cause of incontinence after stroke• Impact of urinary incontinence• Evidence for interventions• How well do we promote continence?• What are the obstacles?• Possible solutions• Questions

Cause of urinary incontinence

• 1 in 3 >40yrs in general population had some bladder problems (Perry et al 2000)

• Around half of all patients admitted to hospital following a stroke will have urinary incontinence (UI)

• 25-50% still have urinary incontinence on discharge (Ween et al 1996, Barratt 2001 and Patel 2001)

Transient causes of urinary incontinence

• Urinary tract infection• Confusion• Disorientation• Drug therapy (diuretics, sedatives etc)

• Severity of stroke rather than site• Gelber (1993)

– Disruption of the neuromicturition pathways resulting in bladder hypereflexia (urge incontinence)

– Neuropathy or medication use resulting in bladder hyporeflexia (retention or incomplete bladder emptying)

– Incontinence due to stroke related cognitive, language or mobility deficits (functional incontinence)

Urgency and urge incontinence

• Sudden, compelling urge to void which is difficult or impossible to defer

• Reportedly the most common type of incontinence after stroke (Khan et al 1990, wyndaele et al 2005)

• ? misdiagnosed

• Bladder wall contains stretch receptors which monitor the content of the bladder

• At around half full, messages are relayed to the brain and perceived as the need to empty the bladder, the fuller the bladder the more intense are the messages to the brain

• The brain send messages to the bladder to prevent contraction until voluntary elimination is required

• After stroke this process is interrupted and there may be few or no messages from the brain to prevent the contractions, even when the bladder is not full

Urinary retention/incomplete bladder emptying

• Acute retention: unable to pass urine spontaneously (may have overflow dribbling)

• Incomplete bladder emptying: bladder not fully emptied (>100mls post micturition)

• Frequent urinary tract infection

Functional incontinence

Stress incontinence

• Not caused by stroke • Pre stroke problems may be exacerbated

The impact of urinary incontinence

• Presence of UI has been shown to be related to poor outcome in stroke survivors and their carers (Nakayama et al 1997)

Impact of urinary incontinence• Sleep loss • Physical discomfort• Self esteem• Depression (twice as common with urinary incontinence, Britten et al

1998)• Rehabilitation• Institutionalisation (Patel et al 2001; Thomas et al 2005)

• Carer stress • Social life

• When at home I live in my underpants unless I’m expecting visitors. It allows me those extra few seconds to reach the toilet. I’m so used to it I take no particular notice now (Godfrey et al 2007)

• I had a bout in hospital about a month or six weeks ago and I came out and I was having to visit the loo to urinate every hour, day and night. Not easy. And I couldn’t go out. I daren’t leave this flat really to go to church, to visit friends, to go shopping or to do anything (Godfrey et al 2007)

• Sometimes I feel I don’t want to go on, you know, carry on, because there’s no pleasure, is there, if you can’t go anywhere or do anything? I think well, why bother, why bother to get up in the morning? (Godfrey et al 2007)

• “I don’t go out, I don’t even ask anyone round ………. I’m so embarrassed about the smell. I do try and keep myself clean but it gets onto your clothes and furniture. Sometimes I wish that I hadn’t survived because it’s no life I’m leading now” (female stroke survivor)

What can be done to improve continence promotion and to increase the number of stroke survivors regaining continence?

Multidisciplinary approach- Improving mobility, communication, memory, assessing the use of aids, prescription of drugs

Nurses are responsible for assessment, diagnosis, care plan and implementation of interventions to promote continence.

Evidence for treatment and interventions for incontinence

• National clinical guidelines for stroke(2008)– Should have protocols for management and treatment of

urinary incontinence

• Cochrane review (2006) – Few RCTs – Suggestive evidence that specialist professional input through

structured assessment and management of care and specialist continence nursing may reduce UI after stroke

– Insufficient data of other interventions to guide continence care

Evidence for interventions

• Nice guidance-management of urinary incontinence in women 2006

• Nice guidance- lower urinary tract symptoms in men 2010

• Guidelines on urinary incontinence-European Association of Urology 2009

• There is some evidence that bladder training may be helpful for the treatment of urge incontinence (Teunissen et al 2004)

• Bladder training is a planned regime to help extend the time between voiding episodes

• Identify the minimum time that a person can hold on between visits to the toilet

• The person then aims to empty their bladder at these intervals throughout the day (not night time)

• If they remain dry on this schedule for two days, the interval is then increased by small amounts (15-30mins)

• If there is no progress with bladder training then a combined approach with medication can be used (Oxybutynin, Tolteridone, Solifenacin etc)

Acute retention

• Acute retention is best managed using intermittent catheterisation (Johansson and Christensson 2010)

• Access to a bladder scanner is essential for this intervention to monitor bladder volume to prevent the bladder from becoming overfull

• If patients are unable to tolerate intermittent catheters (strictures, urethral trauma, personal choice) an indwelling catheter can be used

• There is limited evidence that the use of a valve instead of a drainage bag can help to reduce Urinary tract infection (Doherty 1999; Addison and Rigby 1998;v Fader et al 1997)

• The valve may also help maintain bladder tone and bladder capacity (Addison and Rigby 1998: Fader et al 1997)

• With a valve, there is reduction of trauma to the bladder wall and urethra through the intermittent lifting of the bladder wall from the catheter as the bladder fills. Bladder neck traction may also be prevented as the weight of the drainage bag is not hanging from the catheter (Doherty 1999)

Incomplete bladder emptying

• If patients are symptomatic (incontinence, frequency or UTI) and bladder scan shows>100mls post micturition

• Intermittent rather than indwelling catheters, reduce the risk of symptomatic and asymptomatic bacteriuria (Niel-Wise and Van den Broek 2005)

• IC can be carried out by stroke survivor, carer or Nursing staff between one and five times per day depending on post void residual volume and patient symptoms (Haslam 2005)

Functional incontinence• Prompted or timed voiding involves the identification

of an incontinent persons natural voiding pattern in order to develop an individualised toileting schedule which pre-empts involuntary bladder emptying (Eustice et al 2005).

• Attempts to evaluate the effectiveness of this intervention has been hampered by caregivers not fully maintaining voiding records and difficulty adhering to the timing schedule. (Ostaszkiewicz et al 2004)

• Common sense interventions (call bells, communication aids, hand held urinals etc)

Stress incontinence

• Pelvic floor exercise has been shown to be effective in reducing the amount of leakage caused by stress incontinence and may cure this type of incontinence completely (Bo 1999)

How well do we promote continence?

• Royal College of Physicians-National audit of continence care 2004/2006/2010

• Where a continence problem is identified, assessment or management of that problem is not guaranteed

• Just over half of hospital sites and care homes offer structured training in continence care

• Eighty-five per cent of hospitals had no written policy for continence care

• Documentation of continence assessment and management is wholly inadequate

• In secondary care, two thirds of patients had no documented cause for their incontinence

• Management regimes for older people were predominantly containment methods using pads and catheters (30% catheters used for ‘control of incontinence’ in secondary care)

• National Sentinel Stroke Audit looked at compliance with the standard of having a care plan to promote continence

2001 2004 2006 2008 2010

63% 58% 54% 60% 63%

• 20% of cases were catheterised

• 1 in 10 cases of urinary catheterisation had no clear rationale for the insertion documented (sentinel 2010)

What are the obstacles?

• 2002 St Helier Stroke Unit opened• Audit of continence care showed a lack of

assessment and care which focussed on management and containment of incontinence rather than promotion of continence

• Catheterisation rates were high and there was little documentation of the reasons for catheterisation

• Discussion with nursing staff highlighted several issues.– The assessment tool used by the trust was

complicated and lengthy and consequently rarely used

– Knowledge of evidence based interventions was limited

– Continence status was rarely discussed at multidisciplinary team (MDT) meetings

• New simplified assessment documentation• Stroke unit continence guidelines with

interventions and rationale for each urinary incontinence diagnosis

• Training sessions for all stroke unit nurses and HCAs

• Purchased bladder scanner• Continence status discussed at MDT meetings

and on ward rounds

• Some improvement

• Still only managed 63% of patients with a care plan (National Sentinel Stroke Audit 2010)

• Catheterisation rates below national average at 13% (Sentinel 2010)

• Continence ward rounds

Findings

• A diagnosis cannot be made without an assessment• The assessment requires a post micturition bladder

scan to rule out urinary retention/incomplete bladder emptying

• If the bladder is not emptying properly, patients will find that they are having to go to the toilet frequently because the bladder fills up quickly

• Can be wrongly diagnosed as overactive bladder

• Around a third of patients will have severe strokes which result in reduced conscious level, cognitive deficit and communication problems.

• These patients are often unable to say when they need the toilet or when they are wet

• Nurses will check regularly, but if patients are found wet, the exact time of the void is unknown.

• For timed/prompted voiding a record of how often the patient is wet can help develop an individualised programmed to pre-empt incontinent episodes

• But the problem of recording exactly when voiding occurs prevents an accurate record

• Where an assessment had been completed and a care plan written, review of documentation showed that the proposed timings of intervention was often not followed correctly

• When questioned Nurses suggested that the heavy workload and the fact that they could be responsible for several patients on different toileting schedules made it difficult to keep track

Possible solutions

• Enuresis alarms• Receiver held by Nurses which will accept signals

from up to 7 transmitters• Each transmitter is attached to a patient and a

connected sensor will transmit to the receiver, so that the nurse will know as soon as the patient is wet

• Nursing/care homes, special schools and individuals own homes

• No evidence of use in an acute stroke setting

• Would facilitate post micturition bladder scan• Would benefit patients as not lying in wet

bed/clothes for longer than necessary• Could help prevent soreness and skin

breakdown• Would facilitate accurate record of voiding to

enable an individualised plan of toileting to be made

• Vibrating watches • Can be worn by patients (if cognition and

mobility allow) or by Nursing staff• Can be programmed to remind nurses to take

patients to the toilet at the recommended times/to release catheter valves or to prompt scanning or intermittent catheterisation

• Equipment purchased• Conducting a pilot study to look at

effectiveness in acute stroke setting• Outcome measures

– Number of completed assessments– Number of care plans– Adherence to care plan

• Collection of patient outcome data (feasibility for larger study)

• More research needed

• Acute and early rehabilitation(amenable to assessment/investigation and intervention with close monitoring)

• What happens on transfer of care– Nursing home/residential homes– Rehabilitation units– Individuals own home– Community continence service– District Nursing– Longer term follow up

Questions?

Wendy.brooks@esth.nhs.uk