Understanding Continence

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March 2002

By Gina Peak, RN, CRRN

Urinary and bowel incontinence have long-term implications for patients, so rehab professionals must be knowledgeable on assessment and intervention.

Urinary incontinence (UI) is a major predictor of discharge disposition. UI is defined as the involuntary loss of urine in sufficient quantities to be a problem for the patient.¹ UI affects a person’s independence, sense of self-control, self-esteem, social independence, and sexual satisfaction.

Incontinence has financial implications as well in the health care milieu. In 1996, the Agency for Health Care Policy and Research guidelines estimated the direct costs of incontinence care at $11.2 billion annually in the community and $5.2 billion in nursing homes. Causes of UI include immobility, diminished cognitive status, medications, smoking, low fluid intake, urinary tract infections, constipation, weakness of bladder and support muscles, urethra obstruction, hormonal imbalances, neurologic disorders, and overactive bladder muscles.^1-3

Bladder dysfunction can be categorized into two groups: filling and/or storage dysfunction, which includes bladder overactivity (urge) and urethral underactivity (stress), and emptying dysfunction, which involves bladder underactivity or urethral overactivity (overflow). Although many patients have a combination of symptoms that complicate treatment of UI, there are four broad types of incontinence: urge, stress, overflow, and functional.^1-3

Urge incontinence is the involuntary loss of urine associated with a strong sensation to empty the bladder. Stress incontinence is losing urine with activity. Overflow incontinence occurs when the bladder does not empty completely, thus the bladder overflows and functional incontinence is an absence of lower urinary tract pathology.

Anatomical Overview
The bladder is a muscular organ, which serves as a storage reservoir for urine and has a normal capacity of 250 cc to 400 cc. The detrusor muscle (smooth) of the bladder expands in all directions while maintaining low pressures. Higher pressures are achieved by the mechanisms of the sphincters, tone and elasticity of the urethra, and the pelvic muscles. The internal sphincter remains in a resting state when there is low or moderate pressure. The external sphincter is a striated skeletal muscle and is the last line of defense for maintaining continence.³

The filling phase occurs when the bladder fills and maintains low intravesical pressure with increasing volume. As volume increases, sensory receptors transmit fullness to the sacral cord reflex center (S2, S3, and S4). Sensory messages are sent from the spinal cord to the cerebral cortex through the spinothalamic tract and posterior columns. Inhibitory centers in the frontal lobe can override the micturition reflex by voluntarily contracting the external sphincter, which begins the postponement phase.

The postponement phase becomes more difficult as volume increases, which causes sensory receptors to bombard the sacral reflex center. As bladder pressure increases and approaches the level of urethral pressure, the detrusor muscle begins rhythmic contractions causing discomfort.

The emptying phase begins when messages of fullness and the urge to void are processed in the frontal lobe and motor messages are sent through the corticoregulatory tract to the sacral reflex center. The peripheral nervous system relays messages via parasympathetic and somatic fibers stimulating detrusor muscle contraction, sphincter relaxation, and bladder emptying.³

Neurogenic Bladder
Neurogenic lesions result in varying degrees of incontinence based on the upper motor neuron (UMN) or lower motor neuron (LMN) lesion location. Uninhibited neurogenic bladder is a result of an UMN lesion due to cardiovascular accident, traumatic brain injury, multiple sclerosis, or tumors. Failure of inhibitory fibers of the corticoregulatory tract to suppress involuntary detrusor muscle contractions results in strong uncontrolled voiding contractions of smooth muscle in the bladder wall. Urge incontinence is typical.

Reflex neurogenic bladder is an UMN lesion due to cord lesions above T12-L1. The lesions may be due to trauma, tumors, infection, vascular infarction, or multiple sclerosis. There is disruption of both the sensory and motor nerve tracts above sacral segments two to four. Loss of control from higher brain centers results in uninhibited involuntary detrusor contractions and uncontrolled voiding. The spinal reflex arc takes over control of micturition, which results in decreased bladder capacity with high urine residuals. This bladder may be complicated by an inability of the external sphincter to relax in coordination with detrusor contraction (detrusor sphincter dyssynergia), which causes high bladder pressures.

Autonomous, motor paralytic, and sensory paralytic bladders occur with LMN lesions, which involve a disruption at the sacral spinal reflex arc at S2-S4. Depending on the cause of the lesion, motor or sensory branches are affected. With the autonomous bladder, both motor and sensory fibers are disrupted. Typically, LMN lesions result in increased bladder capacity and overflow incontinence.^2,3

Assessment
Take a detailed health history including traumatic injuries, preexisting conditions, sexually transmitted diseases, diabetes, past surgeries, number of pregnancies and type of delivery, and mental status. Review medications with special attention to diuretics, sedatives, hypnotics, anticholinergics, beta-blockers, and antidepressants. Assess continence history for premorbid status, symptoms, level of awareness of need to void, frequency, quantity, color of urine, dribbling, fluid intake and type of fluid, time of incontinent episodes, and exact methods the client uses to control or manage incontinence. Ask the client to complete a bladder log or void/catheter record for at least 3 days. Consider the client’s functional ability to use a commode chair and assistive devices, as well as the client’s ability to remove clothing and perform hygiene. Access to the bathroom in the home is a top priority in assessment.

Interventions
First, correct constipation. Strive to meet patient/family expectations and motivation. Treat urinary tract infections. Discuss medication review with appropriate providers. Recommend correction of environmental barriers. Maintain hydration between 2,000 and 3,000 cc/day. Decrease or eliminate fluids with diuretic, dehydrating, or irritating effects on bladder such as caffeine, grapefruit juice, and Nutrasweet®. Keep bladder void/catheter log. Maintain the client’s skin integrity.³

Bladder medications impact therapies and functional outcomes, as well as continence. Some of the most commonly used agents⁴ are

Cholinergics (Urecholine). Used to relieve urine retention, they cause detrusor contraction and bladder emptying. Cholinergics increase tone and peristalsis in the gastrointestinal tract. Side effects are headache, bradycardia, hypotension, abdominal cramps, diarrhea, and urgency. They should not be used for patients with urinary obstruction.
Anticholinergics (Antispas, Levsin, Detrol). These inhibit bladder contraction and increase bladder capacity. Anticholinergics decrease gastrointestinal mobility and inhibit gastric acid secretion. Side effects include confusion, palpitations, dry mouth, hypotension, and constipation. Contraindicated for glaucoma patients.
Antispasmodics (Urispas, Ditropan, Pyridium). They depress smooth muscle, produce local anesthesia, and increase bladder capacity. Side effects include palpitations, tachycardia, urine retention, dry mouth, constipation, and confusion. Contraindicated for patients with glaucoma.
Alpha-adrenergic blockers (Flomax). These reduce urethral resistance and facilitate bladder emptying. They help with retention and are used mostly for benign prostatic hyperplasia. Side effects include dizziness, headache, and hypotension.

Bowel Management
Bowel incontinence is typically less of a daily problem and can usually be managed with effective bowel programs and medication management. Constipation and regularity are often the major focus due to client immobility, hydration, and diet concerns. A thorough assessment, both premorbid and current, is important to establish routines and formulate a plan for bowel management. Typically, nurses assess and manage bowel programs in inpatient settings.

In outpatient settings, therapists may discover issues in bowel programs and should feel comfortable referring patients to an appropriate health care provider. Regardless of your professional title, a few basics about bowel care can be relayed to your patients. Most important is that immobility affects bowel routines both physiologically and functionally. The gastrointestinal tract slows with age and disease processes like diabetes. Chronic use of laxatives creates dependence on these products and should be discouraged unless a neurogenic bowel requires their use. Intake of adequate fluid (2,000-3,000 cc per day) and fiber helps with regular consistent stools. Many medications slow the gastrointestinal tract, especially pain medications. Clients on narcotic pain relievers should start stool softeners or a fiber regimen when they begin taking the pain medication.^2,3 Typically, if they wait until there is a problem, it is much more difficult to resolve.

Ostomy Care
The ostomy is the surgical opening and the stoma is the end of the bowel or ureter that protrudes through the abdomen. Colostomy refers to the exit of the colon. These openings may be permanent or temporary. Ileostomy is the small intestine stoma. The stool will have different consistencies depending on the amount of small bowel remaining. Diet impacts ileostomy stool consistency. A urostomy refers to the diversion of urine.

For the most part, clients who require ostomies do not have to change their lifestyles or routines dramatically. However, there can be a significant psychological impact on those with new ostomies and appropriate referrals should be made to organizations, support groups, and counseling services. There are a wide range of products and services available and selecting the correct products for each individual can mean the difference between a healthy active life and social isolation.⁵ For many catastrophically injured patients who require extensive bowel programs that last anywhere from 1 to 3 hours or who have problems with flaccid or atonic bowel accidents, the elective ostomy may result in many benefits.

Continence issues are complex, involving physiological, functional, and environmental factors and can be the major determinate factor in a rehab client’s progress, therefore rehab professionals must consider continence as a top priority in their plan of care.

References
1. Fantl JA, Newman DK, Colling J, et al. Urinary incontinence in adults: acute and chronic management. Clinical Practice Guideline Number Two: 1996 Update. Rockville, Md: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; 1996. AHCPR publication 96-0682.
2. Edwards PA, ed. The Specialty Practice of Rehabilitation Nursing: A Core Curriculum. Glenville, Ill: Association of Rehabilitation Nurses; 2000:112-120.
3. Hoeman S. Rehabilitation Nursing. St Louis: Mosby; 2002:383-444.
4. Nursing 2002 Drug Handbook. 22nd ed. Springhouse, Pa: Springhouse; 2002.
5. United Ostomy Association fact sheets. Available at: www. uoa.org/ostomyinfo.shtml. Accessed December 19, 2001.

Gina Peak, RN, CRRN, has been a rehabilitation nurse since 1994 and is currently director of education at San Antonio Warm Springs Rehabilitation Hospital, San Antonio. She can be reached via email: gpeak@wssahosp.org.

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March 2002