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Fantl JA, Newman DK, Colling J. Urinary Incontinence in Adults: Acute and Chronic Management: 1996 Update. Rockville (MD): Agency for Health Care Policy and Research (AHCPR); 1996 Mar. (AHCPR Clinical Practice Guidelines, No. 2.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

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Urinary Incontinence in Adults: Acute and Chronic Management: 1996 Update.

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4Chronic Intractable Urinary Incontinence

Prevalence and Incidence

The 1979 National Nursing Home Survey estimated the prevalence of UI in nursing homes at 50 percent (National Center for Health Statistics, 1979). A more recent study of 434 nursing home admissions reported the prevalence of incontinence to be 39 percent 2 weeks after admission (Palmer, German, and Ouslander, 1991). The incidence of new cases of incontinence after 1 year for the studied cohort was 27 percent, and remission during the same time period was 30 percent for women and 11 percent for men. The risk factors for UI included physical and mental impairment at both time periods.

Preliminary data from a survey of 8,400 home and hospice health agencies indicate that genitourinary conditions were among the 20 leading first-listed diagnoses for patients added to their caseloads (Strahan, 1994). An earlier study ascertained that UI was one of the 10 leading diagnoses for homebound individuals and first in total charges to Medicare for nursing services per person served (Ruther and Helbing, 1988). In a study of four home care programs in southern Ontario, an average of 22 percent of residents were assessed as incontinent Mohide, Pringle, Robertson, et al., 1988). In a study of low-income, elderly individuals receiving publicly funded home care services, 23 percent were incontinent of urine and generated greater costs because of paraprofessional and other supportive care (Baker and Bice, 1995). In a study of family caregivers, 53 percent of care recipients were found to be incontinent (Noelker, 1987).

These data indicate that UI is common among both nursing home and home care populations. In addition, the number of disabled, dependent nursing home residents increased between 1977 and 1985 Special Committee on Aging, 1988 ). Homebound individuals, by definition, either cannot leave their homes or do so with considerable difficulty as a result of a temporary or chronic disability (Strahan, 1994). The combination of decreased functional ability and UI is a particular challenge to caregivers in both settings. The magnitude of the problem of caring for incontinent homebound individuals will no doubt increase as the absolute number of aged persons increases and as maintenance of dependent, elderly persons at home becomes more common.

Assessment

Since 1990, nursing homes have been required by statute to perform standardized comprehensive assessment and screening of residents upon admission, annually, and when there is a significant change in condition. The Resident Assessment Instrument (RAI), which includes the Minimum Data Set (MDS) and utilization guidelines -- including the Resident Assessment Protocols (RAPs) and triggers -- was developed by the Health Care Financing Administration (HCFA) to improve the quality of care through maintenance and restoration of function (Health Care Financing Administration, 1995). When a patient is incontinent or has an indwelling catheter, assessment is performed using the UI RAP (Boulter, 1993; Resnick and Baumann, 1990). The RAP guides nurses and physicians through the evaluation process to ascertain the cause (including any reversible factors), chronicity (acute vs. chronic), and type of UI experienced by the patient (Resnick and Baumann, 1990). A stress test and evaluation of PVR volume are recommended, and general guidelines are provided for referral for additional evaluation.

The UI RAP does not include evaluation of daily voiding habits, or the frequency, volume, and circumstances of urinary incontinent episodes. Thus, an evaluation using bladder records should be added because it is often important to determine the frequency and severity of the UI to provide appropriate treatment (Wyman, Choi, Harkins, et al., 1988). Formalized assessment of cognitive function is a part of the RAPs. Instruments such as the Folstein Mini Mental State Examination (MMSE) may be helpful in selecting appropriate behavioral intervention (Folstein, Folstein, and McHugh, 1975). Recent data suggest that a short trial is pivotal to assessing responsiveness to a particular intervention Ouslander, Schnelle, Uman, et al., 1995).

Fonda's (1990) definitions of continence status among short-term elderly rehabilitation patients and long-term nursing home residents in Australia can be helpful in evaluating and classifying incontinence. Fonda describes persons who have "independent continence" as those who are able to maintain continence without assistance. "Dependent continence" applies to persons who are physically or mentally impaired and are kept dry through the efforts of others. "Social continence" applies to those incapable of maintaining continence independently or through regular toileting by caregivers and who depend on absorbent products and other measures to contain urine leakage.

The combination of the RAP to assess incontinence and the use of Fonda's definitions can help in evaluating residents and selecting appropriate intervention. The MDS, RAP, and other evaluation tools, however, are not mandated for home care agencies providing skilled nursing visits. Thus, identification of hidden UI depends on the quality of continence questions included in each agency's nursing assessment, and on the skill and knowledge of the nurse. Research in the area of assessment and management of UI among homebound individuals has been performed by nurse investigators (McDowell, Engberg, Weber, et al., 1994; Rose, Baigis-Smith, Smith, et al., 1990). The negative psychological, physical, social, and financial impact of UI on homebound individuals and their caregivers points to the need for a systematic, consistent approach to this problem.

Interventions for Chronic UI

Care of persons with chronic UI should include attention to toileting schedules, fluid and dietary intake, strategies to decrease urine loss at night, use of the most absorbent and skin-friendly protective garments possible, and prevention and early treatment of skin breakdown. (Strength of Evidence = B.)

Before a patient is classified as suffering from chronic intractable UI, the most appropriate intervention should be attempted. This guideline and the consensus of most experts suggest that if the person has stress, urge, or mixed UI, low-risk behavioral treatments should be attempted first if there are no contraindications. Persons with overflow UI who do not have a correctable obstruction may benefit from intermittent catheterization. Some patients may be candidates for surgical or pharmacologic interventions. However, side effects and complications of these treatments are major factors to consider in the treatment of dependent homebound or long-term care patients.

Behavioral Interventions

Studies indicate that behavioral interventions are effective if used by clinicians with training and experience in these methods. Success depends, in part, on using the most appropriate behavioral intervention for each patient. A method for correctly targeting behavioral interventions is to assess cognitive function using a formal test such as the Folstein MMSE (Folstein, Folstein, and McHugh, 1975). Persons who score within the normal range may benefit from interventions that require learning and recall abilities such as PME programs and bladder retraining (Burgio and Engel, 1990; Burns, Pranikoff, Nochajski, et al., 1990; Fantl, Wyman, McClish, et al., 1991; McDowell, Burgio, Dombrowski, et al., 1992; Wells, Brink, Diokno, et al., 1991). On the other hand, persons who demonstrate cognitive impairment on formal testing may benefit from scheduled voiding programs (e.g., prompted voiding or regular scheduled toileting) described in the Behavioral Techniques section of Chapter 3 of this guideline (Colling, Ouslander, Hadley, et al., 1992; Jirovec, 1991; Lekan-Rutledge, Hogue, and Miller 1992; Palmer, Bennett, Marks, et al., 1994; Schnelle, Newman, and Fogarty, 1990).

Toileting Assistance

Prompted voiding and regularly scheduled toileting are effective for preventing urinary accidents in some long-term care or homebound persons (Burgio, Engel, McCormick, et al., 1988; Schnelle, Newman, and Fogarty, 1990; Schnelle, Newman, Fogarty, et al., 1991).

These toileting procedures require the assistance of staff, following a predetermined protocol. Prompted voiding programs require the discernment of wet or dry status and the ability to request toileting, whereas neither of these criteria is necessary for regularly scheduled toileting programs.

Several multisite clinical trials have studied a prompted voiding or scheduled toileting intervention strategy to decrease UI in nursing homes. One study using a 2-week baseline assessment and a 5-week intervention phase examined the effects of a prompted voiding intervention in 30 women whose average age was 85 Creason, Grybowski, Burgener, et al., 1989). Objective evaluation using the Folstein MMSE and the Katz Activities of Daily Living (ADL) measure indicated that 65 percent had severe mental impairment and 78 percent had severe physical impairment. During the intervention, staff approached subjects hourly during waking hours and prompted them to void. Results showed that the experimental group's UI (i.e., percentage of time the patient was wet when checked) was reduced from 40 to 30 percent by the end of the study. The control group's UI increased from slightly more than four episodes to over five per day. Furthermore, all but one of those in the experimental group demonstrated definite patterns of UI that were incorporated into nursing care plans for toileting, and these patients showed continued improvement in UI status. Variations in staff adherence to the intervention may decrease the magnitude of the effect of this treatment.

In a 13-week behavioral therapy program in seven nursing homes carried out by project-trained research assistants 14 hours per day 7 days per week, 133 elderly women were checked hourly and prompted to toilet (Hu, Igou, Kaltreider, et al., 1989 ). Subjects' age averaged 85 years, and most were highly physically and mentally impaired as determined by the Katz ADL instrument and Folstein's MMSE. Subjects in the treatment group decreased the number of their wet episodes from 2 to 1.4 per day. Those who had severe incontinence, more physical dependence, and less mental impairment, as well as normal CMG and bladder capacity, responded better to the training program.

Schnelle, Newman, and Fogarty (1990) enrolled 126 subjects in a multiphase prompted treatment program. Subjects' average age was 82, the majority had severe mental impairment as determined on Folstein's MMSE, and only 11 percent could ambulate independently. During phase 1, which served as baseline, research staff checked each subject hourly for 12 hours per day over a 5-day period and changed them when they were wet. During phase 2, subjects were randomly assigned to immediate- and delayed-treatment groups for 5 days. Those in the immediate-treatment group were prompted to void every hour, asked if they were wet or dry, and then apprised of the accuracy of their response. Finally, they were asked to try to toilet, but were not toileted unless they requested assistance. Subjects were praised both for staying dry and for toileting successfully. Subjects in the delayed-treatment group continued to be checked hourly. Both the immediate and delayed groups participated in the prompted toileting treatment in phase 3. Subjects responded to prompted voiding as follows: 42 percent had less than one incontinent episode per 12 hours; 35 percent decreased their UI by two episodes per 12 hours but were still incontinent one or more times over the 12-hour period; and the rest did not reduce their UI by two or more episodes per 12 hours. The most successful subjects were less than 50-percent incontinent, could recognize when they needed to void, and had higher voided volumes and lower frequency of voiding.

Colling, Ouslander, Hadley, et al. 1992) conducted a clinical trial study among 88 subjects in four nursing homes over a 37-week period. Only subjects with urge or mixed UI were included in the study. Subjects' average age was 85, and all subjects were moderately to severely impaired, physically and mentally, as measured by the Katz ADL and the Short Portable Mental Status Questionnaire (SPMSQ). The study design consisted of a 12-week baseline period, a week during which subjects' individual patterns of voiding were established using an ambulatory electronic monitoring device over a 72-hour period, and a 12-week treatment period with habit training intervention carried out 24 hours per day 7 days per week, followed by a 12-week maintenance period. Data were gathered by research staff for one 24-hour period every 3 weeks throughout the duration of the study by checking subjects every hour. The intervention had three parts: nursing staff received a 4-hour inservice on how to accomplish the treatment, an individual toileting schedule was constructed for each subject based on the electronic monitoring data, and staff and patients received positive reinforcement for adhering to the toileting program and for successful toileting behavior, respectively (Harke and Richgels, 1992). Overall, the intervention significantly decreased UI for 86 percent of the experimental group, with one-third of the group improving more than 20 percent. Incontinence decreased an average of one episode per 24 hours for the entire group. Subjects with greater bladder capacity and less mental impairment responded best to treatment. There was resistance to changing nursing staff routines because of staff shortages, and nursing staff complied with the treatment regimen only 70 percent of the time.

Schnelle, Newman, Fogarty, et al. 1991) noted that 35 percent of nursing home residents were poor candidates for prompted voiding, specifically those who had frequent incontinent episodes, did not respond to prompts, and could not cooperate with toileting. Up to 40 percent of those in the study responded well. Responders can be identified by assessing their responsiveness to a 3-day trial of prompted voiding (Ouslander, Schnelle, Uman, et al., 1995). This may be true for homebound patients as well. Toileting persons according to their individual voiding habits (Colling, Ouslander, Hadley, et al., 1992) is an excellent means of avoiding accidents. If staff is untrained or undersupervised in nursing homes, this intervention is difficult; however, it provides caregivers of homebound patients with a viable management option.

Although research indicates that toileting interventions are promising, they may be compromised, depending on compliance of nursing staff (Campbell, Knight, Benson, et al., 1991; Schnelle, 1990). Nursing staff often expect total continence when these procedures are implemented and become disappointed when this does not occur (Schnelle, Newman, and Fogarty, 1990; Colling, Ouslander, Hadley, et al., 1992; Harke and Richgels, 1992). Several studies point to the importance of monitoring staff implementation of these procedures and providing feedback regarding performance (Burgio and Burgio, 1990; Schnelle, 1990). More research is needed to determine if using predictability of the resident's need to void for an individualized or fixed toileting schedule is more cost-efficient. Future studies should address formal mechanisms of performance appraisal and incentives to increase and maintain staff behaviors that affect patient outcomes. All studies, however, report a modest saving to institutions in laundry and supply costs with the decrease in incontinent episodes.

Homebound Patients

Although management of UI for homebound populations has not been as thoroughly studied as that for those receiving care in a nursing home or ambulatory care setting, two reports focused on the use of PME programs in homebound individuals. Rose, Baigis-Smith, Smith, et al. (1990) reported the successful use of PME training augmented by biofeedback therapy for cognitively intact home care subjects. McDowell, Engberg, Weber, et al. (1994) reported two case studies of severely disabled but cognitively intact homebound individuals who were successfully treated with a biofeedback-assisted PME program. A study of homebound elderly women found that women with UI had significantly less social interaction than continent women (Breakwell and Walker, 1988). Several studies are ongoing using a variety of treatment modalities for both cognitively impaired and cognitively intact homebound persons living in both urban and rural areas.

Physical and Environmental Alterations

All caregivers for elderly or disabled individuals must assess the environment in which the patient resides. Simple alterations, or the addition of toileting or ambulation devices, can often eliminate or reduce episodes of involuntary urine loss. (Strength of Evidence = C.)

Strategies that maintain or improve mobility are likely to prevent or reduce incontinent episodes in the frail elderly. (Strength of Evidence = B.)

Improvement of environmental factors such as access to toilets is likely to enhance treatment and may prevent UI in some cases. Persons who are cognitively intact but who have mobility or balance problems may be unable to suppress an urge until a caregiver arrives to toilet them, or, if they are independent, they are unable to walk or propel their wheelchair to the toilet in a timely fashion. These individuals may benefit from commodes or other external collecting devices such as urinals so that toileting can be achieved more easily. Other persons who can reach the bathroom may find the toilet inaccessible if grab bars and raised toilet seats are not in place.

Studies indicate that improved mobility is associated with remission of incontinence (Jirovec, 1991; Jirovec and Wells, 1990; Palmer, German, and Ouslander, 1991). These studies describe secondary prevention strategies and suggest that a simple walking exercise program not only increases mobility but also decreases the occurrence of UI.

Equipment that enhances mobility such as canes, walkers, and wheelchairs should be available for persons who have problems with ambulation. Toilets need to be at least 17 inches high with arms to assist the patient in lowering to or rising from the toilet seat. Some persons may be unable to reach the bathroom because of distance barriers such as furniture or other objects, poor lighting, or the need to climb stairs (McDowell, Engberg, Weber, et al., 1994). Chairs designed for ease in rising are especially helpful. In one study of elderly, institutionalized residents who were considered chairbound, 77 percent could rise unaided from a chair that was 17 inches at seat height and had arms 10 inches above the seat (Finlay, Bayles, Rosen, et al., 1983).

The use of restraints has been targeted as contributing to UI (Evans and Strumpf, 1990). Physical restraints include various straps and ties as well as "geri-chairs." In addition, sedating drugs can act as chemical restraints that also increase the potential for UI. It is now recognized that alternatives to restraints that maximize freedom of movement but ensure safety of the individual are almost always available.

Studies of specific environmental factors in the management of UI are inadequate to date. Those factors that discourage continence and promote incontinence should be identified and targeted for future research.

Fluid and Dietary Management

Constipation is a common problem for patients with chronic UI. Establishing a bowel regimen based on adequate fiber and fluid intake is often helpful. Elimination of bowel impaction and consequent pressure on the bladder and urethra are often necessary first steps in the treatment of chronic UI. (Strength of Evidence = C.)

Eliminating dietary caffeine such as in coffee, tea, colas, and chocolate is particularly important for persons with urge UI and frequency of urination (Crieghton and Stanton, 1990). However, limiting overall fluid intake is not effective for managing UI. Contrary to popular belief, maintaining adequate fluid intake is important especially for older adults who already have a decrease in total body water and are at risk for dehydration (Davis and Minaker, 1994; Schrier, 1990). In addition, inadequate fluid intake contributes to constipation. Routine use of stool softeners or laxatives should not be encouraged for management of bowel function and prevention of constipation. Laxatives are appropriate for facilitating bowel action prior to other management techniques including dietary fluids and physical activity, but should not be routinely used. Their use may be excessive and inappropriate in older adults. Emphasis should be on dietary measures such as high-fiber foods and fiber supplementation with unprocessed wheat bran and other high-fiber preparations, or the use of bulk-forming agents if dietary measures are neither feasible nor effective.

Management of Nocturia

Night-time voiding and incontinence are major problems for adults of all ages. Preventive measures to decrease night-time voids are recommended. The use of simple electronic urine detection devices should be encouraged for more efficient and effective patient monitoring of night-time urine loss. (Strength of Evidence = B.)

Persons who have nocturia greater than twice a night or who experience enuresis may benefit from fluid restriction and elimination of caffeine-containing beverages in the evening. These individuals should maintain adequate fluid intake by drinking the bulk of their liquids before dinner. Individuals who develop edema of the lower extremities during the day should be advised to elevate their lower extremities several hours during the late afternoon or evening to stimulate a natural diuresis and limit the amount of edema present at bedtime (O'Donnell, Beck, and Walls, 1990 ). In addition, the use of diuretics has been associated with lower night-time urine volumes; altering the timing of the administration of diuretics may decrease nocturia (Ouslander, Schnelle, Simmons, et al., 1993).

In a 10-day study of incontinence in 66 elderly, inpatient men, O'Donnell, Beck, and Walls (1990) found that the highest frequency of incontinent episodes occurred during the 4 p.m. to midnight shift, and the largest volume of urine loss per episode occurred during the night between midnight and 8 a.m. This study utilized an electronic sensor device to measure the frequency and used-pad weight to measure the volume of incontinent episodes. The lower level of physical activity and the mobilization of interstitial fluid that occurs in the supine position were cited as possible causes for these findings. A study by Ouslander, Schnelle, Simmons, et al. 1993), which measured the frequency and volume of urinary accidents for 136 male and female nursing home residents, showed that about 25 percent of the subjects produced significantly more urine at night than during the day.

Although larger studies are needed to better describe the time of day when urine production and excretion occurs, the findings of these two studies point to the need to reconsider continence care during the evening and night-time hours. The issues surrounding continence care during these times are complex and will require coordination of the efforts of long-term care managers, nurses, physicians, manufacturers, and researchers. Some of the issues include adequate staffing during evening and night-time hours, alterations in change routines, use of external collecting devices during these hours for both men and women, and the use of daytime diuretic therapy, as well as other measures described above to decrease edema and the volume of night-time urine production. The continued improvement of absorbent products and the correct use of skin cleaners, barrier creams, and powders are also important. Electronic urine detection devices may in some settings be useful to alert nursing staff of a patient's incontinent void. This would allow wet patients to be changed and permit dry patients to sleep uninterrupted by routine pad checks (O'Donnell, Beck, and Walls, 1990 ).

Other Measures and Supportive Care

Largely because of the introduction and emergence of behavioral therapies to treat UI during the past decade, the aim of continence experts and those who care for incontinent individuals has been to greatly decrease the indiscriminate use of such measures as absorbent pads and garments, external collecting devices, indwelling catheterization, and suprapubic catheters through the successful treatment of UI. However, these measures are beneficial for persons who fail treatment and remain incontinent, who are too ill or disabled to participate in behavioral programs, who cannot be helped by medications, or who have a type of UI that cannot be alleviated by surgical interventions. The judicious use of products to contain urine loss and maintain skin integrity are a first-line defense in these cases.

Protective garments and external collecting devices have a major part in the management of chronic incontinence. The most absorbent and skin-friendly products should always be utilized. However, no scientific literature is available to guide selection of the most effective product. (Strength of Evidence = C.)

Protective Pads and Garments

Absorbent products, classified as disposable or washable, include underpads, pant liners (shields and guards), adult diapers (briefs), and a variety of washable pants and disposable pad systems or combinations (Brink, 1990). In a survey questionnaire mailed to 36,500 Help for Incontinent People (HIP) members throughout the United States, more than 50 percent of the 10,427 respondents reported that they had used some form of protective garment (Jeter and Wagner, 1990). In addition, a survey of 512 community-dwelling elderly men and women with UI showed that 47 percent used absorbent products (Herzog, Fultz, Normalle, et al., 1989). Although there are no studies describing the prevalence of the use of protective garments among incontinent nursing home residents, results of most scheduled voiding programs in nursing homes directly indicate that disposable diapers or reusable pad and pant systems are used by their study subjects (Colling, Ouslander, Hadley, et al., 1992; Schnelle, Newman, Fogarty, et al., 1991).

Very little research has focused on these products despite their frequent use. Brink (1990; 1994) reported that of 30 studies performed between 1965 and 1987 and 14 studies between 1988 and 1993, all but 3 of the latter were performed outside of the United States. One study reported that continence care was labor intensive, requiring 25 minutes per day to change residents (Cella, 1988). In a cost study of UI in nursing homes, Hu, Kaltreider, and Igou 1990) randomly assigned 42 matched pairs of residents to treatment with either disposable or reusable cloth diapers. The total number of pads per day was 5.9 for the disposable pad users and 6.6 for those in the reusable pad treatment group. The average cost per day per person was $2.48 for disposable products and $2.61 for cloth products. Daily cost of disposable products when related to laundry cost revealed a lower daily cost for disposable products ranging from $0.44 to $0.68 or annual savings of $161-$248 per person. In addition, the skin of those using disposable products showed improvement after 1-1/2 months; the skin of subjects using cloth pads and diapers deteriorated.

At present, there are no studies regarding the advantages or disadvantages of the various products available on the market. Data also are lacking comparing reusable with disposable products. Most evaluations are carried out by product manufacturers rather than independent researchers in the health care field and thus carry a bias. This limits their usefulness in assisting nurses, long-term care administrators, and consumers in deciding what products to use. Until objective information is available regarding patient comfort, ease of application and removal, containment of urine, and control of odor, product selection will be made by trial and error or will depend on product availability in the practice setting.

External Collection Devices

External collection devices such as condom catheters can be useful for management of UI in men because they contain urine and keep the skin dry. Although these devices are preferable to indwelling catheters, which have many side effects, adverse reactions do occur. Abrasion, dermatitis, ischemia, necrosis, edema, and maceration of the penis, as well as UTI, can be problems, especially as a result of improper or prolonged use (Ouslander, Greengold, and Chen, 1987a). External catheters need to be applied carefully and changed according to product recommendation and institutional or agency policy. Careful observation of the penile skin and the urine for adverse changes is mandatory.

Although a variety of external catheters is available, no comparative studies have been conducted. There is a need for studies to address the optimal length of time external catheters should be worn before changing and to compare the incidence of UTI and other complications between catheters and external and suprapubic catheters.

Acceptable external collecting devices for women are not widely available. Pieper and Cleland (1993) report that most products developed to date have never been marketed or sold. Still others have been removed from the market because of major problems of leakage and skin abrasions. The literature regarding these products consists of small descriptive studies performed outside of the United States (Pieper and Cleland, 1993). The results of two small studies performed in the United States are encouraging (Johnson, Muncie, O'Reilly, et al., 1990; Johnson, O'Reilly, and Warren, 1989); however, comparative or randomized studies have not been conducted. Thus, conclusions as to the efficiency and safety of these devices cannot be made.

Intermittent Catheterization

Intermittent catheterization appears to be preferable to the use of indwelling catheters for the management of urinary retention and overflow incontinence. (Strength of Evidence = B.)

Persons who have overflow incontinence can benefit from IC. Several studies indicate that IC is preferable to indwelling catheters for both men and women (Kuhan, Rist, and Zaech, 1991; Webb, Lawson, and Neal, 1990; Perkash and Giroux, 1993; Warren, 1990). However, the use of IC in the homebound patient may present considerable difficulty. Most studies have been conducted in young patients with spinal cord injuries. The section on Other Measures and Supportive Devices in Chapter 3 describes the various benefits and problems associated with IC.

Suprapubic Catheters

Suprapubic catheters may be an acceptable alternative for indwelling urethral catheters when patient choice or circumstances require the use of a bladder drainage device. (Strength of Evidence = B.)

Suprapubic catheterization may be an acceptable alternative to indwelling catheters or IC in some patients (Barnes, Shaw, Timoney, et al., 1993; Feneley, 1983; Hebel and Warren, 1990; Stower, Massey, and Feneley, 1989). Small descriptive studies indicate that suprapubic catheterization is a promising method of emptying the chronically full bladder. Large, randomized studies need to be conducted to compare the benefits and risks of this intervention with those of IC and indwelling catheters. In addition, studies should be performed on techniques that prevent the occurrence of complications.

Indwelling Catheters

The use of indwelling catheters should be avoided with few exceptions. They may be useful as comfort measures for the terminally ill, to avoid contamination of decubitus ulcers, and for management of UI in patients with inoperable obstruction that prevents bladder emptying. In Chapter 3, the section on Other Measures and Supportive Devices describes the serious problems associated with long-term use of indwelling catheters.

Skin Care

Recommended measures of cleansing the skin immediately before and after urine loss are helpful in preserving skin integrity. (Strength of Evidence = B.)

Some pads and garments may provide some protection from skin damage. (Strength of Evidence = C.)

Individuals with severe intractable incontinence are often immobile and at major risk for skin breakdown. No one would dispute the importance of good skin care and preventing skin breakdown, yet no randomized, controlled clinical trials have examined the methods most likely to achieve this goal. Recommendations about skin care are generally based on experience or made through marketing materials provided by product manufacturers (DeWitt, 1988; Fowler and Goupil, 1987; Klein, 1988). The most common directions to nurses are to keep the skin dry and keep the patient off any areas of skin breakdown.

Incontinence was noted as one of the risk factors for pressure ulcers in the AHCPR Pressure Ulcers in Adults: Prediction and Prevention. Clinical Practice Guideline ( 1992). The AHCPR guideline panels for Prediction and Prevention of Pressure Ulcers in Adults (1992) and Treatment of Pressure Ulcers (1994) made several recommendations for the prevention of skin chafing and, ultimately, ulcer formation. Because of the lack of scientific evidence, these suggestions were based on expert opinion. Suggested preventive measures included regular inspection of the skin, gentle cleansing with a mild cleansing agent immediately after soiling, avoidance of force and friction during cleansing, use of absorptive briefs or pads, use of topical barriers to protect the skin from moisture, and minimizing skin injury caused by friction and shear through proper positioning, turning, and transfer techniques.

For a full discussion of skin breakdown, with recommendations for prevention and treatment of pressure ulcers, refer to the Clinical Practice Guidelines on pressure ulcers (Bergstrom, Bennett, Carlson, et al., 1994; Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992).

Social and Organizational Milieu of UI

The social and organizational environment of the long-term care facilities can also impact on delivery of continence care. Training programs alone are not effective in changing practice routines from custodial to restorative (Campbell, Knight, Benson, et al., 1991; Colling, Ouslander, Hadley, et al., 1992). Even when well-planned programs exert a positive change on knowledge and attitude, nursing aide behavior may be unchanged (Lekan-Rutledge, Hogue, and Miller, 1992; Smyer, Brannon, and Cohn, 1992; Wagner and Colling, 1993). Long-term care staff are engaged in difficult work with few rewards. Burgio and Burgio (1990) noted in one study analyzing staff behavior that most staff time was spent in patient care activities. Certainly, before practice and management styles in long-term care can be changed, the current physical and social environment, including work patterns and numbers and type of staff, must be thoroughly explored. New nursing practice models such as the use of nurse practitioners and clinical nurse specialists have shown positive impact on resident health outcomes through improved care and decreased hospitalization of residents (Garrard, Kane, Radosevich, et al., 1990; Kane, Garrard, Skay, et al., 1989; Mezey, Lynaugh, and Cartier, 1989).

The few studies of UI in the dependent population in the community have focused on the burden experienced by unpaid caregivers, such as family members caring for dependent elderly persons with UI, and the effect of UI on the health and psychosocial adjustment of incontinent individuals. In all the studies, functional disability (physical, cognitive, or both) was associated with UI Flaherty, Miller, and Col, 1992; Noelker, 1987; Ouslander, Zarit, Orr, et al., 1990). In a study of 299 family caregivers who cared for persons with UI, Noelker (1987) reported significantly more negative effects on family relationships than for caregivers of family members who were continent. However, nearly one-half of the caregivers of persons with UI stated that incontinence was not a problem for them. In another study of 148 caregivers of community-dwelling, chronically ill older persons, 75 percent of those who cared for incontinent family members found maintaining continence burdensome because of time spent in providing care, the care receiver's immobility, and lack of social supports (Flaherty, Miller, and Col, 1992 ). In a study of caregivers of community-dwelling dementia patients with UI, Ouslander, Zarit, Orr, et al. (1990) found that although incontinence was an important factor in many decisions to institutionalize elderly care receivers, UI was rarely the primary reason for nursing home placement, and other factors contributed more to perceived burden. Most of the caregivers indicated that they would be interested in education regarding the care of persons with UI if the sessions were provided in the home.

Although most persons can benefit from behavioral, pharmacologic, or surgical interventions for UI, many others cannot. Typically, these persons reside in long-term care facilities or are homebound and have cognitive or physical impairments that prevent them from learning or performing PME, bladder retraining, or other learned strategies to prevent urine leakage. They do not respond to regular toileting schedules. In addition, these dependent individuals often cannot tolerate or would not benefit from pharmacologic or surgical interventions.

In long-term care facilities, this population is largely cared for by nonprofessional nursing staff. Others are cared for at home most often by family members. Most of the research on UI has focused on reducing or eliminating leakage. Little attention has been given to how to provide the best care for those who do not respond to standard therapies. Studies to ascertain the most effective and efficient methods for specific situations and individual patients are needed to further advance optimal continence care. The care of persons who do not or cannot respond to available therapies must be addressed in randomized, clinically based studies. Currently, continence care for these persons is often based on personal opinion, manufacturers' claims, convenience of the caregiver, or cost of the products.

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