Photo courtesy of Mentor Corp.	More NurseWeek Features   Smoke-Free Zone   Nurses and patients tackle nicotine addiction   Bloodless Survival     Surgical techniques to use when transfusion drops out of the equation
Pessaries and continence rings can be used to control stress urinary incontinence. Shown is Mentor Corp.’s EvaCare line of pessaries, including the dish and ring, left foreground.

Laughter may be the best medicine in some situations, but for the estimated 12 million Americans who suffer from urinary incontinence (UI),¹ the last thing they need is to double over with mirth: For many UI sufferers, that simple reflex can cause a leakage episode. UI itself is no laughing matter for women especially, since they’re twice as likely as men to experience it — along with the almost inevitable stigma.

Urinary incontinence can significantly affect a person’s quality of life by causing profound embarrassment. It limits daily activities and sexual functioning, and it leads to social withdrawal and depression. What’s more, increased urinary tract infections (UTIs) among incontinent women plus injury from falls incurred while hurrying to the toilet put these individuals at additional risk for negative health consequences.²

Beyond the tremendous psychosocial impact, UI also imposes an exceptional financial burden on affected individuals, society, hospitals, and insurers. In 1995, $26 billion was spent directly and indirectly on care for those with UI older than 65.³ This is up from $8 billion in 1984 and $16 billion in 1993.⁴

Sadly, while 80% of UI cases can be cured or significantly improved, women still suffer in silence.³ They fear not being taken seriously. Or they’ve been led to believe that incontinence is just part of growing older, so they just have to come to terms with it. Mean­ while, lives have been quietly rearranged and relationships lost as women avoid having to admit that
there’s a problem.⁵

What can nurses do to help this segment of the population? The first step is having a general understanding of the problem and knowledge of available treatment options.

Female Genitourinary System



This schematic of the normal female genitourinary system points out the pelvic floor muscles, whose healthy functioning has been shown to enhance the urethral closure mechanism. Kegel exercises, which strengthen pelvic floor tissue, can help reverse urinary incontinence.

Types of UI

Urinary incontinence is the involuntary loss of bladder control, which in turn leads to involuntary loss of urine. Typically, UI is categorized four ways, each with different underlying causes.

Stress urinary incontinence (SUI) is the most common form, caused by weakness of the pelvic floor muscles, most often associated with the effects of pregnancy or childbirth. Other possible causes include urethral hypermobility, intrinsic urethral sphincter deficiency, and estrogen deficiency.² Symptoms of SUI involve the loss of urine caused by an increase in abdominal pressure that generally occurs with laughing, sneezing, or coughing or during exercise.

Overactive bladder (OAB), also called urge incontinence or detrusor instability, is another form of UI that stems from a premature bladder contraction. Although the mechanism is poorly understood, the neurological message that normally transmits to the brain the need to void (the micturition reflex) is somehow short-circuited. The detrusor muscle surrounding the bladder contracts, regardless of accumulated bladder volume and without conscious control. This results in an extreme sense of urgency to void, accompanied by the loss of urine present in the bladder. Frequent nocturnal urination is also a common complaint with those affected by OAB. And although the condition is most often of an idiopathic nature, Parkin­ son’s disease, dementia, and cortical damage (resulting from stroke, for example) have been known to contribute to it.²

Overflow incontinence is associated with overdistension of the bladder and subsequent difficulty in emptying its contents. The condition is not as common as the previous two types of incontinence. The kidneys are constantly passing urine through the ureters to the bladder. The bladder fills, but it has a finite capacity. Beyond this level, excess urine will need to pass, resulting in symptoms of constant dribbling or leakage.

A combination of stress and OAB is referred to as mixed incontinence, the fourth category of UI. Although one type is usually more predominant with mixed incontinence, the expressed symptoms may be a mixture of loss of urine with increased abdominal pressure and frequency that appear without warning.

A thorough physical examination is necessary to determine the underlying cause or causes of UI. In some cases, more specialized urodynamic testing may be indicated. Once the full nature of the problem is understood, it’s important to review and discuss all possible treatments, taking into consideration each patient’s unique needs.

Treatment options

Treatment of UI falls into three general categories: behavioral techniques, pharmacological intervention, and surgical correction.

Stress incontinence is most often treated through behavioral techniques. Initial treatment usually starts with efforts at strengthening the pelvic floor muscles. This can be achieved by teaching the patient to perform Kegel exercises daily (see sidebar). It’s important to teach the correct technique and have the patient demonstrate understanding of how to isolate the perivaginal muscles.

Vaginal cones or weights can be used as adjunct therapy. These devices are inserted into the vaginal canal twice a day for 15 minutes each session. By trying to retain the cone or weight, the patient must tighten the perivaginal muscles, as if she were performing a Kegel exercise. This in turn will strengthen the pelvic floor muscles. The items, which come in a kit, are graduated in weight, with a predetermined amount of time spent at each level.