Source: University of Texas at Austin, School of Nursing, Family Nurse Practitioner Program. Recommendations for the management of stress and urge urinary incontinence in women. Austin (TX): University of Texas at Austin, School of Nursing; 2002 May. RECOMMENDATIONS FOR MANAGEMENT OF STRESS AND URGE URINARY INCONTINENCE IN WOMEN Contents * INTRODUCTION * PATHOPHYSIOLOGY * SUBJECTIVE ASSESSMENT * OBJECTIVE ASSESSMENT * DIAGNOSIS * NONPHARMACOLOGIC THERAPY * PHARMACOLOGIC THERAPY * FOLLOWUP * REFERRAL * REFERENCES * Bibliography * Urinary Incontinence Evaluation Tool * Urinary Incontinence: Patient Screening Tools * Sample Voiding Diary INTRODUCTION: * Definition: Urinary Incontinence: The involuntary loss of urine resulting from pathologic, anatomic, or physiologic factors (1, 2) * Stress (SUI): small losses of urine during an increase of intra-abdominal pressure produced from activities such as coughing, sneezing, laughing or exercising; also known as outlet incompetence (3) * Urge (UI): urine loss due to abnormal detrusor muscle contractions and is sometimes associated with some degrees of urinary retention; characterized by an abrupt and strong desire to void; a major component of “overactive bladder” syndrome (3) * Overflow: urine loss due to over-distension of the bladder; symptoms vary and may include urgency, frequent urination, constant dribbling, and both urge and stress incontinence (3,4) * Total: continuous loss of urine with minimal activity, usually seen in women with severe stress UI (3,4) * Functional: urine loss due to acute or chronic impairment of both physical or cognitive function (3,4) * Mixed: symptoms of both stress and urge incontinence (3,4) * Epidemiology: The prevalence of urinary incontinence is difficult to determine for several reasons. Variations in etiology and different definitions of incontinence impair consistent reporting. Definitions of urinary incontinence may range from specifying the occurrence of at least one episode within the last 12 months to specifying incontinence on a daily basis. (1,5) * Urinary incontinence is more common in women than men, although the difference narrows as patients’ age. (1,2,5) * The type of incontinence – urge, stress, or mixed, varies proportionately by sex and age. (5) * In a study of postmenopausal women (mean age 67 years), 56 percent reported urinary incontinence at least weekly. (6) * Stress and urge incontinence are common in postmenopausal women and have different risk factors, suggesting that approaches to risk-factor modification and prevention also might differ and should be specific to the type of incontinence. (6) * Stress incontinence accounts for most incontinence in women younger than 60 years but for only half the cases in older women. (5) * Two recent summary analyses of the prevalence of urinary incontinence yielded similar estimates: the median prevalence of urge and mixed incontinence was about 11 to 13 percent in women aged 30 to 60 and 19 to 24 percent in women older than 60. (5,7) * Several population based studies in the United States found a higher prevalence of urinary incontinence among white women than among African Americans. (5) * A survey of women at a medical school based clinic in 2000- 2001 found that more white women reported urinary incontinence than did black or Hispanic because of their higher stress incontinence symptoms. The percentage of urge incontinence was similar among the three groups; more black and white women reported mixed incontinence; more black women reported frequency and nocturia. (7) * Another study comparing white and Hispanic women found urge incontinence twice as common in whites. (5) The high prevalence of incontinence symptoms among women of different races and ages illustrates that health care providers should routinely screen all women for urinary incontinence. (7) PATHOPHYSIOLOGY: * Continence, control of bladder function, is maintained by voluntary and involuntary mechanisms. The external urethral sphincter and pelvic floor muscles are under voluntary control. The detrusor muscles of the bladder and internal urethral sphincter are under the autonomic nervous system control, which may be modulated by cerebral cortex connections. (2,8) * Factors contributing to urinary continence include adequate estrogen, which may help maintain bladder sphincter tone; adequate bladder capacity, elasticity, and smooth muscle tone; and maintenance of an acute urethrovesicular angle to support the bladder neck and urethra. (2) * Variables shown to be associated with urinary incontinence include age, parity, urinary tract infections, body mass index (BMI), constipation, psychological well-being, lifestyle factor, hysterectomy, and some types of gynecological surgery. (2,8) * Incontinence in women can result from defects in urethral sphincter incompetence, detrusor over-activity or hyper-reflexia, or both. (2,4,6) * Urethral Sphincter Incompetence * associated with weak pelvic ligaments, resulting in loss of support to urethral and bladder neck can contribute to loss of sphincter tone * weakened ligaments allow the urethra to rotate downward during stress which overloads the sphincter causing urethral hypermobility * increases in intra-abdominal pressure with poor ligamentous support and poor sphincter tone may result in involuntary loss of urine * conditions contributing to poor ligamentous support include obstetric trauma and loss of pliability and turgor of the urethral tube through atrophic changes associated from estrogen deprivation * advanced age, inadequate estrogen, previous vaginal surgery, and certain neurological lesions are associated with poor urethral sphincter function * Detrusor Over-activity and Hyper-reflexia * associated with inappropriate contraction of the detrusor muscle during urine storage phase * detrusor muscle contractions causes pressure to rise in the bladder and the patient often perceives a subjective sense of urgency * if pressure rises sufficiently to exceed urethral pressure, leakage results SUBJECTIVE ASSESSMENT: 1. HISTORY 1. Past medical history obtain a complete, detailed medical history with focus on contributing factors such as: (1,2,4,9,10,11,12) * Diabetes * Hypercalcemia * Congestive heart failure * Hypoalbuminemia * Drug induced edema associated with NSAIDs or calcium channel blockers * Chronic lung disease * Fecal impaction * Neurological conditions (e.g. multiple sclerosis, stroke, spinal cord injuries, lumbar disc disease, Parkinson’s disease) * Cognitive impairment * Immobility 2. Obstetric and gynecologic history should include: (2,4,9,10,11,12) * Gravity and parity * Number of vagina, instrument-assisted and cesarean deliveries and complicating factors (eg. degree of lacerations, episiotomy breakdown) * Estrogen or menopausal status * Presence of leiomyomata, endometriosis or pelvic pain * Previous gynecological surgeries, hysterectomy and/or vaginal or bladder surgery * Pelvic radiotherapy trauma 3. Urologic history should include key questions related to: (1,2,4,11) * Number and frequency of UTIs * Urogenital abnormalities * Nature of symptoms and duration (dysuria, frequency, post void dribbling, incomplete emptying, nocturia, hematuria) * Use and number of pads to protect from urine leakage. * Presence of urine leakage without awareness * Stress incontinence * Presence and frequency of leakage of urine * Triggers which increase abdominal pressure (cough, lifting, exercise, sneezing) * Urge/overactive bladder incontinence * Leakage of urine in relationship to urge and frequency * Number of times bladder is emptied during 24 hours * Number of times person empties bladder during night and if it is associated with urge * Mixed incontinence * Symptoms associated with both stress and urge * Overflow incontinence * sensation of being unable to completely empty bladder * frequent or constant dribbling * Behavioral changes made to compensate for incontinence 4. Diet History (11) * Amount of fluid consumed in a 24 hour period * Intake of bladder irritants such as caffeine, alcohol, acidic fruits, tomatoes, sugar, spicy foods, carbonated beverages * Behavioral changes made to compensate for incontinence * Previous attempted therapies and the degree of their success 2. MEDICATION REVIEW (1,2,4,9,10,11,12) * Current prescription medications * Any and all over the counter medications including alternative medications or herbal treatments 3. REVIEW OF FAMILY HISTORY * Any positive history for DM or urological, neurological, or gynecologic pathology 4. PSYCHOLOGICAL HISTORY * Evaluation of coping skills * Evaluation of availability of support systems * Evaluation for sings and symptoms of depression, anxiety, social isolation, low self esteem related to incontinence * Patient goals for treatment OBJECTIVE ASSESSMENT: 1. PHYSICAL EXAM (3,10) * General Appearance: include mobility/dexterity and cognition * Vital signs: including height and weight * Neurological: Focus on lower extremities for strength, DTR’s and perineum by testing with a sharp instrument and noting sensation around the thighs above the knee, and evaluate for anal wink * Abdomen: evaluate for bowel sounds, tenderness ( especially suprapubic), masses, rigidity, guarding, and rebound tenderness * Genitals: note any masses, irritation, discharge, and lesions. Inspect vulva nd vagina for estrogen deficiency, cystocele, rectocele, enterocele, or uterovaginal prolapse, vaginal moisture, strength of pelvic floor contraction * Pelvis: speculum visualization of cervix, including bimanual to evaluate for uterine enlargement, uterine tenderness, cervical motion tenderness, adnexal tenderness/abnormality * Rectum: evaluate for masses and assess for point tenderness as well as pelvic floor strength, fecal impaction 2. RECOMMENDED LABORATORY EVALUATION (10, 13) It is recommended that a urinalysis and if appropriate, a urine C&S and post void residual (PVR) be performed to evaluate for bladder dysfunction. A PVR can be elevated in infection and mechanical obstruction from uterine prolapse. See the attached reference tool "Evaluation and Monitoring of Urinary Incontinence". DIAGNOSIS: (10) _________________________________________________________________ Diagnosis Etiology Age Typical Other _________________________________________________________________ Stress Anatomical Most Loss of small Diagnosed by incontinence changes that common amounts of history lead to in any urine should R/O urethral age associated urinary tract hypermotility women with cough, infection and sphincter except sneezing, weakness the and/or elderly physical activity Urge Abnormal Most Characterized Consider incontinence detrusor common by an abrupt cystocele, muscle in the and strong rectocele, contractions elderly desire to enterocele, and sometimes void, often or associated cannot make it uterovaginal with urinary to the toilet prolapse and retention in time tumors Mixed Traits of both As above 50-60% Consider incontinence stress and commonly cystocele, urge presented form rectocele, incontinence of enterocele, incontinence: or one set of the uterovaginal symptoms is prolapse and most tumors bothersome to the patient Complex Associated Any age Symptoms These history of with spinal associated patients incontinence cord trauma, with etiology should be neurological referred to a disorders, urologist for multiple evaluation sclerosis, etc and management _________________________________________________________________ NONPHARMACOLOGIC THERAPY: * Diet Counseling- should receive diet counseling to limit caffeine intake, such as coffee, tea, colas, and chocolates. Caffeine can overload the bladder causing stress and urge incontinence. Spicy foods and carbonated beverages are bladder irritants. Other diet issues include adequate fluid intake. Dehydration can cause constipation, concentrate urine and increase irritative effects of dietary materials. Limit fluids at bedtime if nocturia is of a particular problem. The recommended fluid intake is 1500-2400 mls. (3) * Behavior Modification- includes bladder training, prompted voiding, and scheduled toileting. A voiding diary should be kept by patient to document each void and episode of incontinence on a daily basis (see the attached sample voiding diary). The diary should be reviewed at each clinic appointment. (3,10) * Pelvic floor exercises- daily kegel exercises can increase strength, control, and coordination. As muscle strength improves, the patient should be taught to increase time of contraction to ten seconds. These can be done in conjunction with auditory and visual biofeedback. Clinical trials of pelvic floor exercises have shown 80-85% improvement of incontinence. These are most effective in women with stress incontinence. (14) * Environmental- evaluates living area, ease of getting to toilet, physical limitations that may impair ability to get to toilet and modify as appropriate for patient. May consider bedside commode. (10) * Social factors- in order to attend social functions such as church, family gatherings, may need to consider use absorbent of products. (3) * Obesity- maintaining optimum weight may decrease urinary incontinence secondary to a decrease in pressure on the bladder and greater urethral mobility (3) PHARMACOLOGIC THERAPY: (Should be used in conjunction with non-pharmacologic therapy) 1. Pharmacologic options for urge incontinence: (4, 10,12,15) a. Anticholinergics are recommended as first-line pharmacotherapy. Tolerodine and Oxybutynin are considered standard therapy. Tolerodine can be considered for use first as a muscarinic receptor antagonist as it has a higher selectivity to bladder receptors and a lower incidence of adverse effects such as headache, fatique and symptoms involving the GI tract and CNS. It has not been associated with significant changes in ECG, BP, standard clinical chemistry or hematologic variables. Table 1 ______________________________________________________ Generic Name Recommended Contraindications Dose ______________________________________________________ Tolterodine PO: 1-2mg BID Known (Detrol, Detrol PO 2-4mg/d hypersensitivity, LA) (Detrol LA) narrow angle * Lower doses glaucoma, GI or should be Urinary obstruction, given in elderly and in hepatic and Renal failure. Oxybutynin PO: 2.5-5mg Known (Ditropan, BID to TID hypersensitivity, Ditropan XL) Titrate: narrow angle increase by glaucoma, GI or 2.5 mg Urinary obstruction, increments every 1-2 d as needed PO: 5mg/d (Ditropan XL) Flavoxate 100-200mg TID GI Bleed, achalasia Propantheline 15mg ac, 30 mg Myasthenia gravis, HS GERD, angle closure glaucoma ______________________________________________________ b. bladder relaxants (for urge incontinence): Table 2 ______________________________________________________ Generic Name Recommended Contraindications Dose ______________________________________________________ Imipramine 10-75 mg q HS Known hypersensitivity Max. 300mg/d to TCAs recovery phase Max 100mg/d in of myocardial infarction elderly Use with caution in cardiovascular disease. Dicyclomine 10-20 mg QID Obstructive uropathy, Max 40mg QID obstructive GI disease, severe ulcerative colitis, myasthenia gravis Hyoscyamine 0.375 mg BID Glaucoma, Obstructive uropathy, obstructive GI disease, severe ulcerative colitis, myasthenia gravis, autonomic neuropathy ______________________________________________________ 2. Pharmacologic options for Stress Incontinence (16, 17, 18, 19) a. Alpha-adrenergic antagonists : Pseudoephidrine 15-30 mg TID b. Localized estrogen replacement therapy Table 3 ______________________________________________________ Generic Recommended Contraindications Name Dose ______________________________________________________ Vaginal Insert into Caution in estrogen vagina every 3 thromboembolic ring months disorders, pregnancy, estrogen dependent Ca, Vaginal 0.5 –1 gm, Breast Ca, undiagnosed estrogen apply in vagina vaginal bleeding, cream q HS impaired liver function ______________________________________________________ Drug therapy should be initiated at the smallest recommended dose and slowly titrated upwards, based on patient response and tolerance. FOLLOWUP: Stress incontinence: Follow up in one month after initial conservative interventions are initiated and diagnostic testing is completed. If symptoms improve continue current interventions and have patient return in one month. If no improvement or sub- optimal improvement as evidenced by severity scale consider pharmacological intervention with pseudoephedrine. Urge incontinence Follow up in one month after initial conservative interventions are initiated and diagnostic testing is completed. If symptoms improve continue current interventions and have patient return in one month. If no improvement or sub- optimal improvement as evidenced by severity scale consider pharmacological interventions (See Tables 1,2,3) Mixed Incontinence Follow up in one month after initial conservative interventions are initiated and diagnostic testing is completed. If symptoms improve continue current interventions and have patient return in one month. If no improvement or sub- optimal improvement as evidenced by severity scale consider pharmacological intervention with Imipramine (see Tables 1,2,3) REFERRAL: Referral is indicated for patients who have failed initial management and for those with a complex history of urinary incontinence. Complex history includes uncertain diagnosis, hematuria without infection, comorbidities such as recurrent UTI’s, severe symptoms of voiding difficulty, severe pelvic organ prolapse, elevated PVR volume or neurologic conditions. Complex urodynamic testing should be performed prior to surgical referral. Any patient with voiding difficulty. The algorithm for "Recommendations for the Management of Stress and Urge Urinary Incontinence in Women" is available on request from the guideline developer. REFERENCES 1. Merkelj, I. (2002). Basic Assessment of urinary Incontinence. Southern Medical Journal, 95, 178-183. 2. Vapnek, J.M. (2001). Urinary Incontinence, Screening and treatment of urinary Dysfunction. Primary Care Geriatrics, 56, 25 – 29. 3. Newman, D.K. (2001) Urinary incontinence and overactive bladder: A focus on behavioral intervention. Topics in Advanced Practice Nursing eJournal, 1, 1-9. 4. Culligan, P.J, & Heit, M. (2000) Urinary Incontinencein Women: Evaluation and Management. American Family Physician, 62, 2433-2444, 2447, 2452. 5. Thom, D.H. (2000). Overactive Bladder: Epidemiology and impact on quality of life. Contemporary OB/GYN, 45, 6 - 13. 6. Brown, J.S., Grady, D., Ouslander, J.G., Herzog, A.R., Varner, R.E., & Posner, S.F. (1999). Prevalence of urinary incontinence and associated risk factors in postmenopausal women. Obstetrics and Gynecology, 94 (1), 66-70. 7. Sze, E.H.M., Jones, W.P., Ferguson, J.L, Barker, C.D. & Dolezal, J.M. (1999). Prevalence of Urinary Incontinence Symptoms among Black, White, and Hispanic Women. Obstetrics and Gynecology, 4, 572-575. 8. Sherburn, M., Guthrie, J.R., Dudley, E.C., O’Connell H.E. & Dennerstein, L. (2001). Is incontinence associated with menopause? Obstetrics and Gynecology, 98 (4), 628-633. 9. Kobashi, K.C. ,Leach, G.E. (2000). Better prospective for stress urinary incontinence, Contemporary Urology, 12, 21-25. 10. Scientific Committee of the First International Consultation on Incontinence, (2000). Making a difference in senior care: A focus on bladder control problems. Lancet, 355, 2153-2158. 11. Preston, M.R., Adam, R.A., (2002). Urinary incontinence in primary care patients. Women’s Health in Primary Care, 2, 111-126. 12. Roberts, R.G. (2000). Current management strategies for overactive bladder, Contemporary OB/GYN, 45, 22-28. 13. Lee, S.Y., Phanumus, D., & Fields, S.D. (2000). Urinary incontinence: A primary care guide to managing acute and chronic symptoms in older adults. Geriatrics, 55, 65-71. 14. Hay Smith Hay-Smith, E.J., Bo, K., Berghmans, L.C., Hendricks, H.J., DeBu, R.A., & Van waalwijk Van Doorn, E.S.C. (2002). Pelvic floor muscle training for urinary incontinence in women (Cochran Review). The Cochran Library, 1, 1-3. 15. Fantl, J. A., Newman D.K., Colling et. al (2000). Urinary incontinence in adults: Acute and chronic management. Rockville Md. Agency for Health Care Policy and Research. 16. Cardozo, L. D., Wise, B.G., Benness, C.J. (2001). Vaginal oestradiol for the treatment of lower urinary tract symptoms in postmenopausal women- a double-blind placebo-controlled study, Journal of Obstetrics and Gynecology, 4, 383-385. 17. Easton, B.T. (2001). Is hormonal replacement therapy (estrogen plus progestin) effective for the treatment of urinary incontinence in postmenopausal women?, Journal of Family Practice, 50, 470. 18. Huffman, G.B., (2000). Behavioral and Drug therapy for urge incontinence. American Academy of Family Physicians, 67, 1635-1637. 19. Messinger-Rapport, B.J., Thacker, H.L. (2001). Prevention for the older woman: a practical guide to hormonal therapy and urogynecologic health. Geriatrics, 56, 32-39. Bibliography Alexander I. M., (2000). Treatment options for urinary Incontinence. American Health Consultants . 21, 84-85 Blavias, J. G., (2001). Overactive bladder: understanding the dysfunctional bladder. Contemporary Urology. 6, 3-15. Bo, B., Talseth, T., Holme, I. (1999). Single blind randomized controlled trial of pelvic floor exercises, electrical stimulation, vaginal cones, and no treatment in management of genuine stress incontinence in women. British Medical Journal. 318, 487-495. Brown, J.S., Posner, S. F., Stewart, A.l.,(1999) Urge incontinence: new health-related quality of life measures. Journal of American Geriatric Society, 47, 980-988. Brown J. S., Ouslander, J.G., Herzog, A. R., Varner, R. E., Posner, S.F., (1999). Prevalence of urinary incontinence and associated risk factors in postmenopausal women. Heart & Estrogen/progestin replacement study (HERS) Research Group. Obstetrics and Gynecology. 94, 66-70. Brugio, K.L., Locher, J.L., Goode, P.S., (1999). Use behavioral therapy for urge incontinence. The Brown University Long-term Care Quality Advisor, 11, 4. Bush, T.A., Castellucci, D.T., Phillips, C. (2001). Exploring women’s beliefs regarding urinary incontinence. Urologic Nursing, 21, 211-216. Butler, R.N., Maby, J.I., Young, G.P. (1999). Urinary Incontinence : Primary care therapies for the older woman. Geriatrics, 54, 31-44. Carson, C. C., (2000). Confronting the urogential consequences of estrogen deficiency. Contemporary Urology, 12, 68-79. Chaliha, C. & Stanton, S. L. (1999) The Ethnic Cultural and social aspects of incontinence- a pilot study. International Urogynecology Journal, 10, 166-170. DiPiro, J.T., Talbert, R.L., Yee, G.C., Matzke, G.R., Wells, B.G., Posey, L.M., (1999). Pharmacotherapy: a Pathophysiologic Approach. Stamford, CN: Appleton & Lange. Fultz, N.H. & Herzog, A.R. (2001). A self reported social and emotional impact of urinary incontinence. Journal of the American Geriatric Society, 49, 892-899. Hagglund, D., Walker-Engstrom, M.L., Larsson, G., Leppert, J. (2001). Quality of life and seeking help in women with urinary incontinence. Acta Obstretricia et Gynecologica Scandinavica, 20, 1051-1055. Hanley, J., Capewell, A., & Hagen, S. (2001). Validity study of the severity index, a simple measure of urinary incontinence in women. British Medical Journal. 322, 1096-1100. Henderson, J.S., Kashka, M.S. (1999). Development and testing of the Urinary incontinence scales. Urologic Nursing, 19, 109-116. Kobelt, G., Kirchberger, I., Malone-Lee, J. (1999). Quality of life aspects of the overactive bladder an the effect of treatment with Tolterodine. British Journal of Urology, 83, 583-590. Kohli, N., Miklos, J. R., Lucente, V., (1999) Tension-free vaginal tape: a mininimally invasive technique for treating female SUL. Contemporary OB/GYN, 44, 141–150. Lubeck, D.P. Prebil, L.A., Peelpes, P., Brown, J. S. (1999). A health related quality of life measure for use in patients with urge urinary incontinence: a validation study. Quality of Life Research, 8, 337-344. Lynch, J.S., (2000) Innovative treatments for common menopausal health problems. Fourth annual conference of the national association of nurse practitioners in women’s health, 1-5. Meade-D’Alisera, P., Merriweather, T., Wentland, M., Fatal, M., Ghafar, M. (2001). Depressive symptoms in women with urinary incontinence: a prospective study. Urologic Nursing, 21, 397-400. Mold, J.W., (1996). Pharmacotherapy of urinary incontinence. American Family Physician, 54, 673-684. Nitti, V.W. (2001). Strategies for effective evaluation and treatment. Contemporary Urology, 13, 14-26. Reilly, N.J., (2000). Nursing management of older women with urinary incontinence. Urologic Nursing, 20, 307-310. Seim, A., Hermstad, R., Humskaar, S. (1997). Management in general practice significantly reduces psychosocial consequences of female urinary incontinence. Quality of Life Research, 6, 257-264. Snyder, K. (1997). No limits: new campaign educates women about incontinence. Drug topics. 141, 82. Supanich, B. (1999) Urethral barriers for stress incontinence. Journal of Family Practice. 48, 662. Thompson, P.K., Duff, D.S., & Thayer, P.S. (2000). Stress incontinence in women under 50: does urodynamics improve surgical outcome? International Urogynecology Journal. 11, 285–289. Thyssen, H., Sander, P., & Lose G. (1999). A vaginal device (continence guard) in the management of urge incontinence in women. International Urogynecology Journal, 10, 219-222. Wagner, T.H., Patrick, D. L., Bavendam, T.G., Martin, M.L., Buesching, D.P. (1996). Quality of life of persons with urinary incontinence: Development of a new measure. Urology, 47, 67-77. Wang, P.S., Levin, R., Shao, S. Z., Avorn, J. (2002). Urinary antispasmodic use and the risks of ventricular arrhythmia and sudden death in older patients, Journal of the American Geriatrics Society, 50, 117-124. Woodman, P. J., Misko, C.A., Fischer, J. R. (2001). The use of short-form Quality of life questionnaires to measure the impact of Imipramine on Women with urge incontinence. International Urogynecology Journal, 12, 312-316. Younkin, E.Q., Davis, M.S. (1998). Women’s Health: a Primary Care Clinical Guide. Stamford, CN: Appleton & Lange. Urinary Incontinence Evaluation Tool __________________________________________________________________ History __________________________________________________________________ Dates of Date Date Date Date Other comments occurrence __________________________________________________________________ Recurrent UTI Pelvic Mass/radiation Pelvic Surgery/fistula Diabetes Neurological disorders Impaired cognition Impaired mobility OB history Gravida__ Para__ Vaginal or C-section __________________________________________________________________ __________________________________________________________________ Symptoms __________________________________________________________________ Yes No Other Comments pertinent to symptom __________________________________________________________________ Incontinence noted with cough or physical activity Urgency or frequency Difficulty voiding/retention Dysuria/BOU Impaired quality of life Medications precipitating incontinence __________________________________________________________________ __________________________________________________________________ Diagnostic Work-up __________________________________________________________________ Date Results Further diagnostics, completed if indicated __________________________________________________________________ U/A and Urine C&S Urine Cytology, if UA abnormal Pelvic/Prostate exam, if indicated Complete metabolic panel PVR Ultrasound of abd/CT scan or abd, etc Urology or GYN referral __________________________________________________________________ __________________________________________________________________ Plan for Diagnosis of___________________________________________ __________________________________________________________________ Date Successful Failed Other tried comments __________________________________________________________________ Bladder training (scheduled voids) with void diary using severity scale Pelvic floor exercises, if indicated Complementary strategies such as biofeedback/acupuncture Diet consult/Fluid monitoring for adequate intake Environmental issues addressed HRT, if indicated Medication trial of________________ __________________________________________________________________ Signature________________________________ Date___________________ Urinary Incontinence Patient Screening Tools Sandvik Severity Scale I. How often do you experience urine leakage (incontinence)? 0 - never 1 - less than once a month? 2 - one or several times a month 3 - one or several times a week 4 - every day/night II. How much urine do you lose each time? 1 - drops/little 2 - more III. Total score (multiply question 1 by question 2). 0 - dry 1 - 2 slight incontinence 3 - 5 moderate incontinence 6 - 8 severe incontinence Incontinence Quality of Life (IQOL) Patient should complete the following prior to visit, if possible. Patient is to rank on a scale as follows: 1- very much, 2 moderately, 3-a little, 4 not at all. Then total all the scores and the higher the score, the better the quality of life. 1. _____ I worry about wetting myself. 2. _____ I worry about coughing and sneezing because of my incontinence. 3. _____ I have to be careful standing up after sitting down because of my incontinence. 4. _____ I worry about where toilets are in new places. 5. _____ I feel depressed because of my incontinence. 6. _____ Because of my incontinence, I don’t feel as free to leave my home for long periods of time. 7. _____ I feel frustrated because my incontinence prevents me from doing what I want. 8. _____ I worry about others smelling urine on me. 9. _____ Incontinence is always on my mind. 10. _____ It’s important for me to make frequent trips to the toilet. 11. _____ I avoid laughing because of my incontinence. 12. _____ Because of my incontinence, it’s important for me to plan every detail in advance. 13. _____ I worry about my incontinence getting worse as I grow older. 14. _____ I have a hard time getting a good night’s sleep because of my incontinence. 15. _____ I worry about being embarrassed or humiliated because of my incontinence. 16. _____ My incontinence makes me feel as if I am not a healthy person. 17. _____ My incontinence makes me feel helpless. 18. _____ I get less enjoyment out of life because of my incontinence. 19. _____ I worry about not being able to get to the toilet on time. 20. _____ I feel like I have no control over my bladder. 21. _____ I have to watch what I drink because of my incontinence. 22. _____ My incontinence limits my choice of clothing. 23. _____ I worry about having sex because of my incontinence. _______ total score Sample Voiding Diary Name: ______________________________________________________ Date: ______________________________________________________ Instructions: Place a check in the appropriate column next to the time you urinated in the toilet or when and incontinence episode occurs. Note the reason for the incontinence and describe your liquid intake (for example; coffee, water) and estimate amount (1 Cup). _________________________________________________________________________________________________________________ Time Fluid No Small Large Activity at Did you Any urine Interval intake- incontinence; incontinence incontinence time of feel a leakage amount Urinated in episode episode incontinence strong between and type toilet urge to urinating? go? How much? Yes or No _________________________________________________________________________________________________________________ 6 - 8 a.m. _________________________________________________________________________________________________________________ 8 - 10 a.m. _________________________________________________________________________________________________________________ 10 - noon _________________________________________________________________________________________________________________ noon – 2 p.m. _________________________________________________________________________________________________________________ 2 - 4 p.m. _________________________________________________________________________________________________________________ 4 - 6 p.m. _________________________________________________________________________________________________________________ 6 - 8 p.m. _________________________________________________________________________________________________________________ 8 - 10 p.m. _________________________________________________________________________________________________________________ 10 - midnight _________________________________________________________________________________________________________________ overnight _________________________________________________________________________________________________________________ number of pads used _________________________________________________________________________________________________________________ time of last drink of fluid before going to bed ______________ *Adapted from National Institute for Health UI Project: Dixon, Koneski, Roberts All copyrights are reserved by the University of Texas at Austin, School of Nursing, Family Nurse Practitioner Program.