Incontinence and stroke
Wendy Brooks
Stroke Nurse Consultant
Epsom and St Helier University
Hospitals NHS Trust
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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
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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
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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 (1530mins)
• 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)
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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
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Nursing home/residential homes
Rehabilitation units
Individuals own home
Community continence service
District Nursing
Longer term follow up
Questions?
Wendy.brooks@esth.nhs.uk