Incontinence and stroke

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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

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Cause of urinary incontinence

• 1 in 3 gt40yrs 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)

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Transient causes of urinary incontinence

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

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• 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)

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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

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• 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

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Urinary retention/incomplete bladder emptying

• Acute retention unable to pass urine
  spontaneously (may have overflow dribbling)
• Incomplete bladder emptying bladder not fully
  emptied (gt100mls post micturition)
• Frequent urinary tract infection

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Functional incontinence
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Stress incontinence

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

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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)

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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

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

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• 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 couldnt go out. I darent
  leave this flat really to go to church, to visit
  friends, to go shopping or to do anything
  (Godfrey et al 2007)

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• Sometimes I feel I dont want to go on, you know,
  carry on, because theres no pleasure, is there,
  if you cant go anywhere or do anything? I think
  well, why bother, why bother to get up in the
  morning? (Godfrey et al 2007)

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• I dont go out, I dont even ask anyone round
  . Im 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
  hadnt survived because its no life Im leading
  now (female stroke survivor)

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• 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.

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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

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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

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• 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)

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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

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• 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 1998v 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)

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Incomplete bladder emptying

• If patients are symptomatic (incontinence,
  frequency or UTI) and bladder scan showsgt100mls
  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)

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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)

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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)

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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

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• 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)

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

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

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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

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• 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

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• 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

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• 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

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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

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• 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.

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• 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

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• 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

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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

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• 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

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• 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

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• 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)

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• 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

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• Questions?

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• Wendy.brooks_at_esth.nhs.uk