Urinary incontinence
Urinary incontinence: Excerpt from Nursing: Interpreting Signs and Symptoms
Urinary incontinence, the uncontrollable passage of urine, can result from a bladder abnormality, a neurologic disorder, or an alteration in pelvic muscle strength. A common urologic sign, incontinence may be transient or permanent and may involve large volumes of urine or scant dribbling. It can be classified as stress, neurogenic, overflow, urge, or total incontinence. Stress incontinence refers to intermittent leakage resulting from a sudden physical strain, such as a cough, sneeze, laugh, or quick movement. Neurogenic incontinence occurs due to an unawareness of the need to void caused by spinal cord injury. Overflow incontinence is a dribble resulting from urine retention, which fills the bladder and prevents it from contracting with sufficient force to expel a urine stream. Urge incontinence refers to the inability to suppress a sudden urge to urinate. Total incontinence is continuous leakage resulting from the bladder's inability to retain urine.
History and physical examination
Ask the patient when he first noticed the incontinence and whether it began suddenly or gradually. Have him describe his typical urinary pattern: Does incontinence usually occur during the day or at night? Does he have any urinary control, or is he totally incontinent? If he can occasionally control urination, ask him the usual times and amounts voided. Determine his normal fluid intake. Ask about other urinary problems, such as hesitancy, frequency, urgency, nocturia, and decreased force or interruption of the urine stream. Also ask if he has ever sought treatment for incontinence or found a way to deal with it himself.
Obtain a medical history, especially noting urinary tract infection (UTI), prostate conditions, spinal injury or tumor, stroke, or surgery involving the bladder, prostate, or pelvic floor. Ask a woman how many pregnancies she has had and how many childbirths. A diary of voiding habits for a 24- to 48-hour period may provide useful information. Obtain a complete drug history.
After completing the history, have the patient empty his bladder. Inspect the urethral meatus for obvious inflammation or anatomic defect. Have female patients bear down; note any urine leakage. Gently palpate the abdomen for bladder distention, which signals urine retention. Perform a complete neurologic assessment, noting motor and sensory function and obvious muscle atrophy.
Medical causes
Benign prostatic hyperplasia (BPH).Overflow incontinence is common with BPH as a result of urethral obstruction and urine retention. BPH begins with a group of signs and symptoms known as prostatism: reduced caliber and force of urine stream, urinary hesitancy, and a feeling of incomplete voiding. As obstruction increases, urination becomes more frequent, with nocturia and, possibly, hematuria. Examination reveals bladder distention and an enlarged prostate.
Bladder cancer.With bladder cancer, the patient commonly presents with urge incontinence and hematuria; obstruction by a tumor may produce overflow incontinence. The early stages may not produce symptoms. Other urinary signs and symptoms include frequency, dysuria, nocturia, dribbling, and suprapubic pain from bladder spasms after voiding. A mass may be palpable on bimanual examination.
Diabetic neuropathy.Autonomic neuropathy may cause painless bladder distention with overflow incontinence. Related findings include episodic constipation or diarrhea (which is commonly nocturnal), impotence and retrograde ejaculation, orthostatic hypotension, syncope, and dysphagia.
Multiple sclerosis (MS).Urinary incontinence, urgency, and frequency are common urologic findings in MS. In most patients, vision problems and sensory impairment occur early. Other findings include constipation, muscle weakness, paralysis, spasticity, hyperreflexia, intention tremor, ataxic gait, dysarthria, impotence, and emotional lability.
Prostate cancer.Urinary incontinence usually appears only in the advanced stages of prostate cancer. Urinary frequency and hesitancy, nocturia, dysuria, bladder distention, perineal pain, constipation, and a hard, irregularly shaped, nodular prostate are other common late findings.
Prostatitis (chronic).Urinary incontinence may occur as a result of urethral obstruction from an enlarged prostate. Other findings include urinary frequency and urgency, dysuria, hematuria, bladder distention, persistent urethral discharge, dull perineal pain that may radiate, ejaculatory pain, and decreased libido.
Spinal cord injury.Complete cord transection above the sacral level causes flaccid paralysis of the bladder. Overflow incontinence follows rapid bladder distention. Other findings include paraplegia, sexual dysfunction, sensory loss, muscle atrophy, anhidrosis, and loss of reflexes distal to the injury.
Stroke.With a stroke, urinary incontinence may be transient or permanent. Associated findings reflect the site and extent of the lesion and may include impaired mentation, emotional lability, behavioral changes, altered level of consciousness, and seizures. Headache, vomiting, visual deficits, and decreased visual acuity are possible. Sensorimotor effects include contralateral hemiplegia, dysarthria, dysphagia, ataxia, apraxia, agnosia, aphasia, and unilateral sensory loss.
Urethral stricture.Eventually, overflow incontinence may occur with a urethral stricture. As obstruction increases, urine extravasation may lead to formation of urinomas and urosepsis.
UTI.Besides incontinence, a UTI may produce urinary urgency, dysuria, hematuria, cloudy urine and, in males, urethral discharge. Bladder spasms or a feeling of warmth during urination may occur.
Other causes
Surgery.Urinary incontinence may occur after prostatectomy as a result of urethral sphincter damage.
Nursing considerations
▪ Prepare the patient for diagnostic tests, such as cystoscopy, cystometry, and a complete neurologic workup. Obtain a urine specimen.
▪ Implement a bladder retraining program. (See Correcting incontinence with bladder retraining.)
▪ If the patient's incontinence has a neurologic basis, monitor him for urine retention, which may require periodic catheterizations.
Patient teaching
▪ Explain the underlying disorder and treatment plan.
▪ To prevent stress incontinence, teach the patient how to perform Kegel exercises to help strengthen the pelvic floor muscles.
▪ Teach the patient self-catheterization techniques, as appropriate.
Pictures
Book Source Details
- Book Title: Nursing: Interpreting Signs and Symptoms
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Nursing: Interpreting Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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