BAB I

INTRODUCTION

A. Foreword
According to the National Institute of Aging in the United States, urinary
incontinence affects at least 1 out of 10 people aged 65 years or older. Studies in
Singapore indicate that about 1 in 7 people aged 60 years and above have urinary
incontinence. Many older people mistakenly believe that it is a normal part of aging.
Urinary incontinence can affect people from any age group and from every socio
economic level. It is more common in women.
Urinary incontinence can be an embarrassing and uncomfortable condition that
can directly affect not only a persons health but also the quality of everyday life. Some
people who have urinary incontinence become socially isolated because of the fear of
wetting themselves or creating an unpleasant odour from the leakage of urine. Many
suffer in silence and hide the problem from family and friends. Nurses can play an
important role in helping patients to understand and manage urinary incontinence and
improve their quality of life. In connection with this, we are pleased to present the
guidelines on Nursing Management of Patients with Urinary Incontinence
There is little evidence for the necessity to carry out a clinical examination.
However, there is wide agreement that clinical examination is essential. In a patient with
UI, this should include abdominal examination, to detect an enlarged bladder or other
abdominal mass, and perineal and digital examination of the rectum and/or vagina.
Examining the perineum includes an assessment of oestrogen status in women and a
careful assessment of any associated genitourinary prolapse. A cough test will often
reveal stress incontinence, but only if the bladder contains urine during the examination.
Pelvic floor contraction is assessed by means of digital vaginal examination. In men, it is
essential to perform a digital examination of the rectum and prostatic assessment.

B. Purpose
1. Knowing what urinary incontinence is
2. Knowing types of urinary incontinence
3. Knowing prevalence and causes urinary incontinence
4. Knowing diagnostic test and treatment for urinary incontinence
5. Knowing nursing care plan for patient with urinary incontinence

BAB 2
STUDY LITERATURE

A. Definition
Urinary incontinence (UI) is an extremely common complaint in every part of the
world. It causes a great deal of distress and embarrassment, as well as significant costs, to
both individuals and societies. Estimates of prevalence vary according to the definition of
incontinence being used and the populations being studied. However, there is universal
agreement about the importance of the problem, both in terms of human suffering and
economic costs.

B. Types Of Urinary Incontinence

1. Stress Incontinence
Stress Incontinence is an involuntary loss of urine due to an increased intraabdominal pressure during coughing, sneezing, laughing or other physical activities
that increase intra-abdominal pressure.
2. Urge Incontinence
Urge Incontinence is the involuntary loss of urine associated with a strong desire or
need to urinate. It is usually, associated with premature detrusor muscle contractions,
referred to as detrusor instability. Although detrusor instability can be associated with
neurologic disorders, it also occurs in individuals who appear to be neurologically
normal. Urge incontinence is a result of a sudden, involuntary bladder contraction
caused by inflammation or irritation within the bladder. This inflammation or
irritation may be due to calculi, malignancy, infection or atrophic vaginitis-urethritis.
These uncontrollable contractions can also occur when the brain centre that inhibits
bladder contractions is impaired by neurologic conditions such as stroke, Parkinsons
disease or dementia. Urge incontinence is the most common type of incontinence in
older people.
3. Mixed Incontinence
Mixed Incontinence is a combination of both stress and urge incontinence. It is most
common in older women.

4. Overflow Incontinence
Overflow Incontinence is the involuntary loss of urine resulting from an overdistended bladder. It may have a variety of presentations, including frequent or
constant dribbling, or urge or stress incontinence symptoms. Overflow may be caused
by an inactive or acontractile detrusor, or bladder outlet or urethral obstruction. The
bladder may be underactive or acontractile secondary to drugs, neurologic conditions
such as diabetic neuropathy, low spinal cord injury, or radical pelvic surgery that
interrupts the motor innervation of the detrusor muscle. The detrusor may also be
underactive from idiopathic causes. In men, it is often related to enlarged prostate and
impacted faeces.
5. Transient Incontinence
Transient Incontinence is a result of a reversible medical condition. The patients may
be suffering from delirium, urinary tract infection, atrophic vaginitis, psychological
problem (such as depression), endocrine disorder, impaired immobility and/or stool
impaction. It may be due to drugs such as diuretics and sedatives.
6. Functional Incontinence
Functional Incontinence is the involuntary urine loss caused by factors outside the
lower urinary tract such as impairment of physical or cognitive functioning, or both.
It is important to note that immobile and cognitively impaired individuals may also
have other types and causes of UI.

C. Prevalence
Studies in Great Britain and Europe have found the prevalence of urinary
incontinence in older patients in hospitals to be between 18 percent and 40 % in men, and
24% and 46 % in women. In elderly persons living in the community the prevalence has
ranged from 5% to 25 % in men, and from 7% to 42% in women.
There are several reasons these prevalence figures are so varied-including whether
the study was done in the community or institutions, the timing of the study in relation to
acute illness, and how the investigators defined incontinence and asked about the
problem. Because urinary incontinence is such a heterogeneous condition, a precise
definition is important for studying the problem systematically.

It is probably best to define incontinence in a general way (such as "any

uncontrolled leakage of urine at any time") and to develop a classification based on its
severity, using the number of incontinent episodes per day, or even measuring tF amount
of urine by weighing soiled underclothes. In a recent British survey, which more
precisely defined incontinence and included older persons in the community as well as in
institutions, 11 percent of men anid 17 percent of women were found to have some
problem with urinary incontinence.
Whatever the precise prevalence, it is clear that millions of elderly persons
throughout the world are afflicted with this condition, and many more probably suffer
with it while failing to admit its presence.

D. Factors Associated With Incontinence

There is very little information characterizing those with this disorder. Factors
that may have important implications for prevention, prognosis and management remain
to be defined.
A relation between urinary incontinence and cognitive impairment has been
recognized in a few studies but this was older patients in institutions, where the
prevalence of cognitive impairment approaches 50 percent; the importance of this
information alone is therefore uncertain. Most of the elderly seen at one outpatient
incontinence clinic in Great Britain did not have substantial cognitive impairment and
also could walk without assistance, but the important relationship between these
characteristics and the severity of the incontinence was not described.
One important factor associated with incontinence in the elderly is acute illness.
Previously continent older persons often become incontinent when admitted to hospital
for a variety of acute conditions." This relationship may explain the transience of urinary
incontinence in up to a third of such persons in some studies.9"'1
The relationship between acute illness and incontinence is important because
appropriate management of the incontinence during this period of acute illness may
prevent a transient problem from becoming established, with attendant complications.

E. Causes Urinary Incontinence In Elderly

Aspect of Continence Affected
Comorbidity
Ability to get to toilet
1. Functional impairment, e.g., from arthritis,
Parkinsons, poor vision
2. Extrapyramidal effects of antipsychotic medications
3. Medications causing sedation or confusion, e.g.,
benzodiazepines
4. Poor access to toilets
5. Severe cognitive impairment: advanced dementia,
severe depression
Fluid balance
1. Excessive intake of caffeinated beverages, alcohol
2. Increased nocturnal diuresis from congestive
failure, sleep apnea, venous stasis, or drugs; causing
peripheral
edema
(e.g.,
amlopidine,
thiazolinediones, gabapentin)
3. Diuretic medications
Urethral closure
1. Marked obesity
2. Cough because of pulmonary disease, ACE
inhibitors
3. Increased urethral tone from alpha adrenergic
agonists, decreased tone from alpha blockers
Bladder contractile strength
1. Medications impairing bladder contractility:
calcium channel blockers, anticholinergics, opiates
2. Diabetes (advanced), vitamin B 12 deficiency,
lower spinal cord injury
Uninhibited bladder
1. CNS diseases, stroke, suprasacral spinal cord
contractions
diseases
2. Diabetes
3. Local bladder irritation: stones, carcinoma
F. Diagnostic Test
1. Bladder stress test
You cough vigorously as the doctor watches for loss of urine from the urinary
opening.
2. Urinalysis and urine culture
Laboratory technicians test your urine for evidence of infection, urinary stones, or
other contributing causes.
3. Ultrasound
This test uses sound waves to create an image of the kidneys, ureters, bladder, and
urethra.

4. Cystoscopy
The doctor inserts a thin tube with a tiny camera in the urethra to see inside the
urethra and bladder.
5. Urodynamics
Various techniques measure pressure in the bladder and the flow of urine.

G. Treatment
1. Behavioral Remedies: Bladder Retraining and Kegel Exercises
By looking at your bladder diary, the docttor may see a pattern and suggest
making it a point to use the bathroom at regular timed intervals, a habit called timed
voiding. As you gain control, you can extend the time between scheduled trips to the
bathroom. Behavioral treatment also includes Kegel exercises to strengthen the
muscles that help hold in urine.
The first step is to find the right muscles. One way to find them is to imagine that
you are sitting on a marble and want to pick up the marble with your vagina. Imagine
sucking or drawing the marble into your vagina.
Try not to squeeze other muscles at the same time. Be careful not to tighten your
stomach, legs, or buttocks. Squeezing the wrong muscles can put more pressure on
your bladder control muscles. Just squeeze the pelvic muscles. Dont hold your
breath. Do not practice while urinating.
Repeat, but dont overdo it. At first, find a quiet spot to practiceyour bathroom
or bedroomso you can concentrate. Pull in th pelvic muscles and hold for a count of
three. Then relax for a count of three. Work up to three sets of 10 repeats. Start doing
your pelvic muscle exercises lying down. This is the easiest position to do them in
because the muscles do not need to work against gravity. When your muscles get
stronger, do your exercises sitting or standing. Working against gravity is like adding
more weight.
Be patient. Dont give up. It takes just 5 minutes a day. You may not feel your
bladder control improve for 3 to 6 weeks. Still, most people do notice an
improvement after a few weeks. Some people with nerve damage cannot tell whether
they are doing Kegel exercises correctly. If you are not sure, ask your doctor or nurse

to examine you while you try to do them. If it turns out that you are not squeezing the
right muscles, you may still be able to learn proper Kegel exercises by doing special
training with biofeedback, electrical stimulation, or both.
2. Medicines for Overactive Bladder
If you have an overactive bladder, your doctor may prescribe a medicine to block
the nerve signals that cause frequent urination and urgency.
Several medicines from a class of drugs called anticholinergics can help relax
bladder muscles and prevent bladder spasms. Their most common side effect is dry
mouth, although larger doses may cause blurred vision, constipation, a faster
heartbeat, and flushing. Other side effects include drowsiness, confusion, or memory
loss. If you have glaucoma, ask your ophthalmologist if these drugs are safe for you.
Some medicines can affect the nerves and muscles of the urinary tract in different
ways. Pills to treat swelling (edema) or high blood pressure may increase your urine
output and contribute to bladder control problems. Talk with your doctor; you may
find that taking an alternative to a medicine you already take may solve the problem
without adding another prescription.
Scientists are studying other drugs and injections that have not yet received U.S.
Food and Drug Administration (FDA) approval for incontinence to see if they are
effective treatments for people who were unsuccessful with behavioral therapy or
pills.
3. Biofeedback
Biofeedback uses measuring devices to help you become aware of your bodys
functioning. By using electronic devices or diaries to track when your bladder and
urethral muscles contract, you can gain control over these muscles. Biofeedback can
supplement pelvic muscle exercises and electrical stimulation to relieve stress and
urge incontinence.

NURSING CARE PLAN FOR PATIENT WITH URINARY INCONTINENCE

1. Assesment
Take a history from the person identified to have UI, history-taking should include:
Past medical/ surgical/ obstetric and gynaecological history
Medications
Duration of UI
Circumstances of leak e.g. coughing, straining, sense of urgency
Bladder storage symptoms e.g. frequency, urgency, nocturia
Any voiding symptoms e.g. intermittency, poor stream, post-void dribble, straining
Psychological and social history

2. Physical Examination
Conduct systematic physical examination to identify abnormalities that have a direct
bearing on the incontinence.
Check for fluid retention.
Assess skin condition around the genitoperineal region and check for skin excoriation.
Assess functional state. Examine and determine patients mobility, cognition and manual
dexterity.

3. Nursing Care Plan

1. Instruct the patient to cough forcefully when the bladder is full and observe for urine
leakage.
Rationale:
Stress incontinence is likely if instantaneous urine leakage occurs with cough.
2. Send a sample of urine for urinalysis and culture as ordered by Doctor.
Rationale:
Urinalysis detects any contributory factors e.g. haematuria, glucosuria, pyuria, bacteriuria
and proteinuria. Urine culture is done to exclude urinary tract infection.
3. Measure Post Voided Residual (PVR) volume by in-out catheterisation or bladder
scanning within a few minutes after voiding.

Rationale:

Less than 50 mls is considered adequate bladder emptying.

Repeated PVR volumes in excess of 100 mls are considered inadequate emptying.

4. Record frequency, timing and amount of voiding preferably for three days using a
bladder chart.
Rationale :
The bladder chart is probably the single most useful nursing tool in assessing the
individuals level of UI. It provides baseline information, helps to monitor progress and
effectiveness of therapy.
5. Timed voiding/scheduled toileting is recommended throughout the whole day for patients
who need assistance for toileting
Rationale:
Systematic effort is required to motivate the patient to delay voiding and resist urge. The
goal is to achieve continence by preempting involuntary bladder emptying. There must be
regular opportunities for micturation.
6. Habit training is recommended for patients with whom a natural voiding pattern can be
determined.
Rationale:
Habit training involves matching toileting schedule to patients voiding habits.
Frequency, volume, patterns of continence and incontinence are adjusted. The voiding
schedule fits the patients established pattern.
7. Prompted voiding (usually at 2 hourly intervals) is recommended for patients who can
learn to recognise some degree of bladder fullness or the need to void, or who can ask for
assistance or respond when prompted to void. The patient is asked at regular intervals
whether voiding is required and is assisted to the toilet if the response is positive.
Rationale:
When voiding is successful, reward with praise and words of encouragement
8. Bladder training is strongly recommended for management of urge UI
Rationale:
Bladder training helps the patient to postpone voiding according to a schedule, to
provide for larger voiding volume, and longer intervals between voiding.

 Bladder training appears to be effective in reducing the frequency of stress and urge
UI. Studies have indicated cure rates of 10 to 15% and improvement in the majority of
patients.
9. Pelvic floor muscle exercise is beneficial to women with stress incontinence.
Rationale:
Pelvic floor muscle exercise strengthens the voluntary periurethral and pelvic floor
muscles, the contraction of which exerts a closing force on the urethra. This technique
has been emphasised for women with stress UI but appears to be useful in men as well.
Benefit has been reported in 30 to 90% of women, but criteria differ among studies.
Patients with mild symptoms may improve most. Continued exercise is required for
continued benefit.
Pelvic floor muscle exercise enhances other therapies including insertion of vaginal
cones, electrical stimulation and behavioural training.

BIBLIOGRAPHY

Kuchel, George A., Catherine E. Debaue. 2009. Journal: Urinary Incontinence In The Elderly
Chapter 30. American Society of Nephrology

Moh Nursing Clinical Practice Guidelines 1/2003. 2003. Nursing Management Of Patients With
Urinary Incontinence. Singapore: Ministry Of Health

National Institute Of Diabetes

And Digestive And Kidney Disease. Journal: Urinary

Incontinence In Women. U.S Department Of Health And Human Service: National Institute
Of Health

NURSING CARE MANAGEMENT

FOR PATIENT WITH URINARY INCONTINENCE

CREATED BY
EKO YEPPIANTO

131411123039

RACHMAD HANDANI

131411123031

DIMAS

131411123033

LULUK ANGGARANI

131411123035

GRANDIS DWI K

131411123037

YAN LARAS M. Q.

131411123039

ASTRID DYAH F

131411223042

PROGRAM STUDI PENDIDIKAN NERS

FAKULTAS KEPERAWATAN
UNIVERSITAS AIRLANGGA SURABAYA
2014