Assessment and Management of Urinary Incontinence

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Abstract
Urinary incontinence (UI) is defined as any involuntary leakage of urine. 1 Awareness of UI as a clinically important health disorder amenable to treatment has grown among healthcare professionals and the public. Treatment of UI has shifted from a hygienic problem to a disorder calling for individualized diagnosis and treatment. Nurses have long had a leading role in UI assessment and management 2 and nurse practitioners (NPs) are particularly well-suited to screen, diagnose, and manage UI in the primary care and specialty practice settings. When UI is defined as any urine loss under any circumstances, prevalence in women is approximately 50%, but this number falls to 8% to 36% when prevalence is limited to bothersome urine loss. 3–5 The prevalence of UI among work-aged men is much lower, from 2% to 9%. 6,7 Urinary incontinence prevalence rises in elderly adults regardless of sex. Its prevalence in community-dwelling elders in the United States is 20% to 30% and 42% to 56% in nursing homes. 8–10 Urinary incontinence is divided into types based on symptoms or underlying pathophysiology (see Table: “Types of Urinary Incontinence”). 1 Three types (stress, urge, and mixed) account for approximately 90% of adult cases. 3,11 Stress UI accounts for approximately one-half of all cases, urge UI accounts for approximately one-third of all cases, and mixed UI accounts for one-quarter to one-third of all cases. Case control studies show multiple risk factors for UI. 3,11 Evidence-based education is critical when counseling patients about these risk factors (see Table: “Potential Risk Factors Associated with UI”). 3,4,12–39 The effect of UI on health and quality of life is related to the frequency and volume of urine loss and degree of urinary urgency. 40 Patients with occasional easily-concealed episodes of urine loss tend to report little impact on quality of life. 41,42 When the patient can no longer hide the condition from others, it profoundly affects quality of life. 43–46 The negative psychosocial effects of UI are magnified by urinary urgency. Urinary incontinence can increase the risk of job loss or impaired performance evaluations. Teachers, librarians, and others may face sanctions when frequent urination conflicts with job demands. In a study of women in a production facility, 16% were unable to toilet unless they arranged for someone to assume their responsibilities and 3% were repeatedly unable to void. 47 Severe UI is associated with a reduced life expectancy among frail elders in long-term care facilities. 48 Urinary incontinence also increases the risk of urinary tract infections (UTIs) in postmenopausal women, 49 the risk of falls and hip fracture in elderly women, 50 and the risk for stage 1 and stage 2 perineal wounds. 51 Screening for UI is indicated in high-risk groups including women, men after prostate surgery, and persons with paralyzing neurological disorders. 40,52,53 Sampselle and colleagues 53 advocate four questions to screen for UI: 1) Do you ever leak urine/water when you do not want to? 2) Do you ever leak urine/water when you cough, laugh, or exercise? 3) Do you ever leak urine/water on the way to use the bathroom? 4) Do you ever use pads, tissue, or cloth in your underwear to catch urine? Using these four questions, 57% of a sample of 1,474 women reported UI on at least one screening opportunity and 63% pursued evaluation and treatment.