Self-Monitoring for Management of Urinary Incontinence

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Self-Monitoring for Management of Urinary
Incontinence

• Molly C. Dougherty, PhD, RNProfessor
• Jean Kincade, PhD, RNResearch Associate
  Professor
• John R. Carlson, MSAssistant Professor
• The University of North Carolina at Chapel
  HillChapel Hill, NC, USA

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Goal of Presentation

• Discuss a single idea
• Based on clinical observation
• Idea was tested through research
• Results Evidence-based recommendations
• For women with urinary incontinence (UI)

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A Metaphor for the Presentation

• A metaphor is a figure of speech containing an
  implied comparison.
• Here, the development of research in urinary
  incontinence (UI) is compared to running a relay.

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UI Research As a Relay Race

• Think about runners, coaches, handing off the
  baton.

Think about running towards the finish line.
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The ApproachHanding Off the Baton

• Chronological over 20 years
• Sequential
• Results build

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Original Idea

• Among women with UI, simple steps result in large
  improvement for some women.

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UI Studies in the Mid-1980sStretching Our
Muscles

• Included simple steps
• Within other behavioral interventions
• Consequence
• Simple steps contributed to error variance and
  affected the experimental outcome

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Manage Measurement ErrorStay on Track

• Control for simple steps
• Place simple steps first in protocol
• Measure baseline after simple steps and before
  randomization into Randomized Controlled Trial
  (RCT)

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Trust Clinical Observation

• Simple steps are important on their own.
• Simple steps should be tested in an RCT.

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Both ApproachesWe Have Run It Both Ways

• Meritorious
• Provide important results

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Multiple Studies Mid-1980sMore Early Winners

• A whole century ago!
• Behavioral management for UI research growing
• Research funding available
• Publications, new knowledge

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Several Studies Showed

• Regardless of behavioral intervention studied,
  intervention and control group improved.

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Keeping a Bladder Diary

• Self-monitoring
• Changed urinary patterns
• Improved UI

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Simple StepsRunner One Leaves the
BlockDougherty et al., 1993
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Overview of First Study

• Pelvic Floor Muscle Exercise (PFME)
• Intervention for Stress Urinary Incontinence
  (SUI)
• Results supported use of PFME

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Changes in Urine Loss Variables at Baseline,
After the Control Period, and at PME Levels 2 and
4
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Primary Outcome Variable

• Grams of urine loss in 24 hours
• Measured by pad test

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Secondary Outcome Variable

• Episodes of urine loss in 24 hours
• Measured by bladder diary
• Self-report of episodes

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Simple Steps

• Keep a bladder diary
• Maintain fluid intake
• Limit caffeine ingestion
• Discuss effect of over-the-counter medications on
  UI

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Bladder Diary

• Cornerstone of UI research
• Episodes of UI primary variable
• Literature support reliability and validity
• Clinical observation, logic support
• Diligence decreases in many with diary keeping
  over time during an intervention

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Bladder Diary

• Many forms
• One form each 24-hour period
• Hourly time blocks
• Simple to complex

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Simple Bladder Diaries

• Hourly time blocks
• Woman checks beside hour each time she has a
  urine loss episode
• Needed for elderly and disabled participants

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Complex Bladder Diaries

• Hourly time blocks
• Woman records
• Episodes of urine loss
• Amount and type of fluid intake
• Voluntary voids
• Other information

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Control Period

• Careful instruction on keeping bladder diary
• General instructions on fluid intake and caffeine
• Review of over-the-counter medication
• Discussion of their effect
• No specific instruction about medications given

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Control Period Results

• Keeping a bladder diary had an effect
• Related to
• Quality of counseling
• Learning from bladder diary
• Effect not statistically significant
• Could be important
• Controlling error
• As intervention

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Community-Based, RCT StudyHand Off the Baton to
Runner TwoDougherty et al., 2002
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Overview of RCT Study

• Intervention Behavioral Management for
  Continence (BMC)
• Three phases
• Self-monitoring (simple steps)
• Bladder training
• PFME with biofeedback

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Self-MonitoringPhase 1, Criteria

• Caffeine intake 2 cups or glasses/day
• Fluid intake lt1,500 or gt4,000 cc/day
• Excessive voiding interval average 4 hours
• Constipation self-reported
• If did not meet any criterion, advance to Phase 2

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Self-MonitoringPhase 1, Goals

• Reduce caffeine gradually to no more than 2
  caffeinated beverages/day
• Increase (lt1,500 cc) or decrease (gt4,000 cc)
  fluid intake gradually, to 1,800-2,400 cc/day
• Reduce voiding interval to 2-3 hours during
  waking hours
• Increase fiber

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Bladder TrainingPhase 2

• Protocol Wyman and Fantl (1991)
• Guided women to
• Void at scheduled time intervals
• Gradually increase the voiding interval

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PFME with BiofeedbackPhase 3

• Biofeedback with surface electromyography (EMG)
• Observe and modify quality of pelvic floor muscle
  contractions
• PFME
• Goal 45 contractions per day
• Three times a week for 12 weeks

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Outcome Measures

• Primary grams of urine loss in 24 hours
• Secondary episodes of urine loss in 24 hours

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Analysis Plan

• Intervention (BMC) evaluated as a whole
• Results supported the efficacy of BMC
• Significant reductions in grams of urine loss
• Also in episodes of urine loss
• Results sustained over 2 years

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Mean Grams Loss per 24 hr at Baseline and Four
Follow-ups in BMC and Control Groups
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BMC Group Looking Inside the Intervention
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BMC Group Looking Inside the Intervention
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BMC Group Looking Inside the Intervention
Tomlinson et al., 1997
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AnalysisCaffeine Intake

• Linear regression
• Decrease in caffeine intake
• Decrease in episodes of urine loss
• Approached statistical significance (p .07)

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AnalysisChange in Fluid Intake

• Increase in fluid intake
• Increase in volume of urine voided (p .05)

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AnalysisDaytime Voids

• Fewer daytime voids of intervals greater than 4
  hours
• Increase in volume of urine voided (p .04)
• No change in urine loss

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Results Indicate

• Simple steps merit more attention
• Need for RCT on simple steps

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Weakness of Self-Monitoring

• Cannot be applied to all women with UI
• One or more criterion does not apply to all
• Drink too much or too little, too much caffeine,
  etc.

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Design Issues

• Bladder diary
• Promotes improvement in UI
• Bladder diary alone
• No significant improvement
• Competitive funding not likely

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Simple Steps Design Issue

• Caffeine reduction
• Fluid intake modification
• Long voiding interval
• Alleviation of constipation
• Improvement in UI
• Promising
• Not clearly significant
• All women with UI do not need simple steps

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RCT Research

• Participants assigned to a condition
• Experience that condition

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The KnackNumber Three Runs AheadMiller,
Aston-Miller, DeLancey (1996)
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What Is The Knack?

• Precisely timed pelvic floor muscle contraction
• Practice in clinic to reinforce learning
• Used before activities that result in urine loss
• Significantly reduces urine loss
• Women with stress urinary incontinence

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Knack Quick Kegel

• Simple step
• Appropriate to all women with UI
• Important addition to simple steps

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Using Quick Kegel

• Most women probably use it
• Nearly all women can use it

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RCT on Self-Monitoring Runner Four Comes Around
the BendKincade, Dougherty Carlson, 2000-2006
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Study Design

• Random assignment
• Self-monitoring
• Wait-list group
• Bladder diary and pad tests
• Baseline
• Follow-up

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The Intervention

• Counseling and instruction
• Simple steps
• Caffeine 12 oz or more caffeinated beverages/day
• Fluid intake
• 50 oz or less total fluids
• 133 oz or more total fluids
• Constipation one or more bowel symptoms (Kincade
  et al., 2005)
• Quick Kegel all participants

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Outcome Measure

• Pad tests
• Grams of urine loss in 24 hours

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Results
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ConclusionsSimple Steps, Significant Improvement

• Urine loss (gm)
• Women with stress and mixed UI

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ImplicationsThe Ideal Training Schedule

• Simple steps should be first steps
• Management of stress and mixed UI
• Use bladder diary
• Counsel women
• Follow up on progress
• Add Quick Kegel instruction

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Summary
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Overall Implications

• Women should be screened in all clinical settings
  for bladder control problems.
• Women should be offered evidence-based
  counseling.
• Sampselle et al., 1997

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Review

• Follow-up on one clinical observation
• Use results from one study
• Build rationale for next
• Support importance of simple steps
• Any nurse can implement

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Keep Running to the Finish Line
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The University of North Carolina at Chapel Hill
NC, USA