URINARY INCONTINENCE

URINARY INCONTINENCE
Elmarina, S.Kep

I. INTRODUCTION
The urinary system consists of the kidney, the bladder, the ureters and the urethra. The kidneys filter the blood to remove waste products and form urine. The urine flows from the kidneys, down through the ureters to the bladder. From here it passes through another tube called the urethra to the outside when urinating (weeing) (Wocare Management).

II. DEFINITION
Incontinence can be defined as the involuntary and uncontrolled passage of urine or stool or both (Doughty Dorothy B, 2000).
The International Incontinence Society (ICS) define UI as the complaint of any involuntary leakage of urine.
The Urinary Incontinence Guidelines Panel defines UI as the involuntary loss of urine which is sufficient to be a problem.

III. PREVALENCE & INCIDENCE

More than 13 million Americans – male and female, young and old – have incontinence. Women are more likely to leak urine than men (http://kidney.niidk.nih.gov/.).
From the AGS Foundation for Health in Aging, Urinary Incontinence is a problem for at least 30 % of people over age 60. It is more common in women than men.
On Practical Stoma Wound and Continence Management state that UI is more prevalent in females than in males due to anatomical difference, childbirth, and hormonal changes. The prevalence of regular UI in female was cited by Norton in 1986 as 8.5 % for 15 – 64 year old, and 11.6 % for women over 65 years, whereas male urinary incontinence is reported as 1.6 % to 65 years and 6.9 % over 65 years.

IV. TYPES OF INCONTINENECE
According to ICS on Urinary and Fecal Incontinence Current Management Concept identified four major types of incontinence, there are:

A. Stress Incontinence

Stress Incontinence is defined subjectively as the complaint of involuntary leakage on effort or exertion, or on sneezing or coughing. Objectively it is defined as the observation of involuntary leakage from urethra synchronous with exertion/ effort, or sneezing or coughing.
Stress Incontinence is thought to be caused by increased abdominal pressure. Urodynamic stress incontinence is defined as the involuntary leakage of urine during increased abdominal pressure, in absence of detrussor contraction.
The causes of stress incontinence:
1. Pelvis floor muscular trauma: often an outcome of childbirth or pelvic fracture.
2. Atrophy of pelvic floor muscle: a consequence of estrogen deficit that is associated with menopause or aging.
3. Weakness of pelvic floor musculature: a consequence of stretching due to chronic constipation and persistent straining at stool or caused by obesity.
4. Damage to muscle innervations: a result of trauma from childbirth, sacral fracture, or caudal equine lesions.
5. Weakened or surgically damaged sphincters.

B. Urge Incontinence

Urge incontinence is characterized by frequent loss of urine associated with a sudden, strong; urgent desire to void the bladder begins to empty before the toilet is reached. A major caused is uninhibited contraction of the detrusor muscle frequently associated with neurological disorder.
The cause of urge incontinence:
1. Detrusor instability or irritability
2. Sensory irritations of the bladder due to inflammation or infection.
3. Decreased bladder capacity and bladder spas me.
4. Decreased outlet resistant.
5. Pressure from abdominal or bladder mass.

C. Reflex Incontinencele,

Reflex incontinence indicates loss of volitional control of voiding caused by a ladder with loss of pelvic sensations. Recently it called as neurogenic lower urinary tract dysfunction. By definition, this type of dysfunction occurs only in patient with neurologic disorder.

D. Overflow Incontinence
Overflow incontinence was previously defined as any involuntary loss of urine associated with over distention of the bladder.
The causes of overflow incontinence:
1. Bladder neck obstruction by for example, prostatamegaly or urethral stricture, urinary calculus or bladder tumor.
2. Diabetic neuropathy weakening the detrusor muscle so contraction are ineffective.
3. Side effect of certain medications for example tricyclic antidepressant.
4. Neurological lesions, spinal cord trauma or tumor, multiple sclerosis.
5. Surgical trauma to pelvic nerves.

Subsequent report have added types and terms to the major types of incontinence, there are:
A. Mixed UI, also known as mixed stress – urge incontinence is defined as the complaint of urinary leakage associated with urgency and also with exertion, effort, sneezing, and coughing.
B. Enuresis is a synonym for incontinence and is defined as any involuntary loss of urine; nocturnal enuresis is the form that should be used to denote loss of urine occurring during sleep.
C. Extra urethral incontinence is defined as the observation of urine leakage through channels other than the urethra, this type of continence is typically the result of an ectopic ureter or fistula.
D. Uncategorized incontinence is defined as the observation of involuntary leakage that cannot be classified into one of the foregoing categories on the basis of signs and symptoms.

V. MANAGEMENT

A. The management of stress incontinence are:
Pelvis floor exercise. Pelvic floor exercise are base on principle exercise physiology, the individual with incontinence is thought to strengthen the striated muscle component of the sphincter mechanism. The potential benefit of pelvic floor exercise in the treatment of the stress urinary incontinence were first describe by Kegel.
Home exercise program. after teaching the patient to correctly contract the pelvic floor muscle, the nurse provide the patient with written and verbal instruction for home exercise regiment. The regiment consist of two types of exercise for strength and exercise for endurance.
Pessary Device. Stress incontinence in women may also be manage by placement of an appropriate pessary device. A pessary device is a ring-shaped, doughnut-shaped, spherical, or oblong device manufactured of vulcanized rubber or some inert material. The device is placed in the vaginal vault and replaced as necessary.
Pharmacologic manipulation. Stress incontinence may also respond to pharmacologic manipulation. Women with evidence of estrogen deficiency may be treated with topical or systemic estrogen.

B. The management of urge incontinenece are:

Elimination of bladder irritant. Bladder irritant such as infection rarely cause incontinence, however irritant factor can acerbate urinary frequency and leakage and should be eliminated.
Prompted voiding and bladder drill program. bladder drill therapy similar to a prompted voiding regimen in that the patient is ask to void according to a timed schedule.
Fluid control. The goal of fluid control is to distributed the intake of baferage through out weaking hours, so that the urinary inacontinece system is not forced to cope with a large volume of liquid in a brief period of time.
Pharmacological manipulation. The goal of pharmacologic therapy is to increase functional bladder capacity by decreasing detrussor contractility, for example: propanteline, oxibutinin, imipramine.

C. The management of Reflex Incontinece.
The goal in the management of the patient with reflex incontinence is to establish a program that provides the patient with a socially acceptable level of urinary dryness while protecting the kidneys from damage.
Clean intermittent catheterization. Clean intermittent catheterization provides complete regular bladder emptying and is associated with an acceptability low rate of urinary tract infection.
Reflex voiding and condom drainage. Such a program is feasible only for patient who do not have bladder sphincter dyssynergia. For the patient who is using a program of reflex voiding for bladder management, nursing management focuses on care of the condom drainage device and prevention of associated complications.

D. The management of overflow incontinence.

The nursing management of urinary retention or overflow incontinence is directed toward eliminating urinary statis and correcting or managing urinary incontinence. Treatment option may include double voiding and fluid control program, pharmacologic manipulation, clean intermittent catheterization, indwelling catheter and surgical correction of the underlying obstruction.
Double voiding and fluid control program. a program of double voiding may be effective in case of mild to moderate out late obstruction.
Pharmacologic manipulation. This program may be used to relieve urinary retention caused by outlet obstruction.
Intermittent catheterization may be used to manage urinary retention.
Indwelling catheter. This program sometime necessary for the management of urinary retention.

REFERENCE

Doughty, Dorothy B. 2000. Urinary and Fecal Incontinence Current Management Concepts Third Edition. Mosby: Elsevier.

Blackey, Patricia. 2004. Practical Stoma Wound and Continence Management Second Edition. Research Publication Pty Ltd: Vermont, Victoria, Australia.

Doughty, Dorothy B. 1991. Urinary and Fecal Incontinence Nursing Management Concepts . Mosby: St. Louis, Missouri.

Wocare Management- Incontinence Management Journal

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