”ms osvaomam or A PHYSICAL assassmzwnom FOR, ' UTILIZATION OF THE AGENCY FOR HEALTH. CARE mum AND RESEARCH eumamas 0N URINARY . INCONTINENCE IN AMBULATORY CARES j - ' Schaiaréy ngect 15mm Degree 0% as. 3-, ix: MICHXGAN 3mg UNIVERSITY » , » MICHELLEFEDEWA _ ' ‘ 2000 LIBRARY Michigan State University 7- A? *a’zfiOZf ‘--~- PLACE IN RETURN BOX to remove this checkout from your record. TO AVOID FINES return on or before date due. MAY BE RECALLED with earlier due date if requested. DATE DUE DATE DUE DATE DUE 6/01 c:/CIRC/DateDue.p65-p.15 DEVELOPMENT OF A PHYSICAL ASSESSMENT TOOL FOR UTILIZATION OF THE AGENCY FOR HEALTH CARE POLICY AND RESEARCH GUIDELINES ON URINARY INCONTINENCE IN AMBULATORY CARE BY Michelle Fedewa A SCHOLARLY PROJECT Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE College of Nursing 2000 ABSTRACT DEVELOPMENT OF A PHYSICAL ASSESSMENT TOOL FOR UTILIZATION OF THE AGENCY FOR HEALTH CARE POLICY AND RESEARCH GUIDELINES ON URINARY INCONTINENCE IN AMBULATORY CARE BY Michelle Fedewa Urinary incontinence should not be accepted by women as an inevitable and untreatable condition. The primary care provider is the cornerstone of evaluation. Evaluation components include: screening, thorough history and physical, diagnosis, initiation of treatment and/or referral. A physical assessment tool will assist the primary care provider in data collection. TABLE OF CONTENTS LI ST OF FIGURES O O O O O O O O 0 O O O O O O O O O O 0 INTRODUCTION Background . . . . . . . . . . . . . . . . . . . . Problem Statement . . . . . . . . . . . . . . . . Project Purpose . . . . . . . . . . . . . . . . . Conceptual Definitions . . . . . . . . . . . . . . CONCEPTUAL FRAMEWORK . . . . . . . . . . . . . . . . . Health Promotion Model . . . . . . . . . . . . . . REVIEW OF LITERATURE . . . . . . . . . . . . . . . . . Prevalence and under-reporting . . . . . . . . . . Quality of Life . . . . . . . . . . . . . . . . . costs 0 O O O O O O O O O O O O O O O O O O O O O Underdiagnosis . . . . . . . . . . . . . . . . . Evidence Based Medicine and Practice Guidelines . PROJECT DEVELOPMENT . . . . . . . . . . . . . . . . . . Overview Description of Evaluation Components . . . . . . . Implementation . . . . . . . . . . . . . . . . . . IMPLICATIONS FOR PRACTICE . . . . . . . . . . . . . . . IMPLICATIONS FOR RESEARCH . . . . . . . . . . . . . . . IMPLICATIONS FOR PROFESSIONAL EDUCATION . . . . . . . . SUMMARY . . . APPENDICES: Appendix Appendix Appendix Appendix Appendix Appendix Appendix A: Urinary Incontinence Screening Questions . . . . . . . . . . . . . . B: Incontinence Impact Questionnaire and Urogenital Distress Inventory: Short Forms . . . . . . . . . . . . . . . . C: Incontinence History Form . . . . . . D: Bladder Record . . . . . . . . . . . . : Physical Exam Tool . . . . . . . . . F: Provider Letter and Information . . . G: Information Packet . . . . . . . . . . LIST OF REFERENCES . . . . . . . . . . . . . . . . . . iii Page . iv 0 m4>hrahI O 00‘ . 19 . 19 . 23 . 26 . 28 . 29 . 31 . 31 . 34 . 45 . 52 . 53 . 56 . 57 . 58 . 59 Figure Figure Figure Figure 1: 2: 3: LIST OF FIGURES Health Promotion Conceptual Model . Health Promotion Conceptual Model with Decision and Action Phases AHCPR Guidelines for Management of Urinary Incontinence in Primary Care . Pelvic Muscle Rating Scale iv Page . 32 . 42 INTRODUCTION Background Urinary incontinence (involuntary leaking of urine) is a prevalent, under diagnosed and underreported condition. It can occur when any of the normal functions of the bladder are disrupted. Today, urinary incontinence in women of all ages is seen as a major healthcare concern. Increased awareness of this condition began in 1988 at the National Institutes of Health Consensus Conference on Adult Urinary Incontinence. Following this, in December 1989, the US Department of Health and Human Services Agency for Health Care Policy and Research (AHCPR) was established and in 1992 issued the first publication of Clinical Practice Guidelines for Adult Urinary Incontinence. These summarized and evaluated the most recent research and clinical care in the field. These guidelines were designed to enhance the quality, effectiveness and appropriateness of the health care in the area of incontinence. Since that time there has been an increased focus on the problem of urinary incontinence. These Guidelines were updated in 1996 and three documents were released by the AHCPR: 1) The Clinical Practice Guideline; 2) Urinary Incontinence in Adults: Acute and Chronic Management; and3) The Quick Reference Guide, Understanding Incontinence (AHCPR, 1996). These documents emphasize the problem of urinary incontinence and provide the foundation for assessment and treatment methods. Urinary incontinence is a common problem that affects a significant proportion of the otherwise healthy general population. Approximately twenty percent of women between the ages of 25 and 64 years experience urinary incontinence (Herzog & Fultz, 1990). The prevalence will increase as the "baby boomer" segment of the American population continues to age. Although urinary incontinence is most common in elderly women (Lagace et a1., 1993; Burgio, Matthews, & Engel, 1991) it is not an inevitable part of aging. Many women affected by incontinence will not seek treatment because of the belief that incontinence is a normal part of aging and/or childbirth, because of embarrassment, and/or the belief that urinary incontinence cannot be treated (Jolleys, JV 1988). According to Burgio et a1. (1994) fewer than half of the individuals living in the community consult their health care providers about this problem. Quality-of-life (QOL) is effected by urinary incontinence. Many women cope with the problem by utilizing the widespread availability of absorbent products that helps control the problem (Rekers, Drogendijk, Valkenburg, & Riphagen, 1992) or by making adjustments in their lifestyles. Dependency on these products gives the woman a feeling of security and acceptance of the condition and decreases motivation to seek evaluation and treatment (Staber & Loboe, 1985). Studies completed by Grimby et al. (1993), Hunskaar and Vinsnes, (1991), and Jackson, (1997) concluded that women experiencing urinary incontinence were more socially isolated and had significant effects on their daily lives. Most women with urinary incontinence reside in the community (Burgio et al., 1991). Primary care providers can take an active role in identifying, evaluating and managing urinary incontinence in these women. There is a growing body of knowledge concerning the clinical care of individuals with urinary incontinence. Several federal and private organizations have provided research funding for the study of urinary incontinence (AHCPR, 1996). Many current studies indicate that urinary incontinence has effective treatments but that there is a need for increased awareness of the problem by healthcare providers and the public at large. Alleviating barriers to obtaining treatment, such as embarrassment and misconceptions about incontinence, requires public education and dissemination of information about incontinence by health care providers. Such information will dispel myths and destigmatize the problem. Targeting of appropriate groups for health education, clinical assessment, and intervention is necessary to alleviate and/or modify incontinence. Providers can be proactive in promoting continence among women by increasing public awareness, providing education, and consistently and purposely asking about urinary incontinence with each contact. EIle§m_SL§L£m§nL Urinary incontinence is a complex problem. It is associated with a significant impact on aspects of quality of life (QOL). From the existing data it is not difficult to gauge the reality of the widespread occurrence and existing need to improve identification, evaluation and treatment in the primary care setting. In order to do this, the author suggests the development of a tool to assist the primary care provider in implementing the AHCPR practice guidelines. BMW Primary healthcare providers need to ask women about incontinence as a part of routine screening and physical examinations. There is increased availability of various treatment modalities as well as improved information and education to assist in correcting commonly held misconceptions about urinary incontinence (i.e., the inevitability and untreatability). This enables more women to receive treatment for this prevalent and largely underreported condition. Many primary care physicians and advanced practice nurses, (APN) may not be sufficiently trained in the identification, management and appropriate referral of urinary incontinence. The outcome of this scholarly project is to develop an ambulatory care physical assessment tool to assist in systematically implementing the AHCPR clinical guidelines for physical examination. The goal is to ultimately increase the clinicians' likelihood of exploring urinary incontinence with women and to improve women's quality of life, decrease their urinary symptoms and related costs through better urinary incontinence identification and care. This tool will enhance the providers' ability to identify characteristics of urinary incontinence, and to initiate interventions and/or referral when appropriate. This project is of particular importance for advanced practice nurses due to their focus on health promotion and disease prevention. i ! J I E' 'l' Definitions: Urinary Incontinence. Urinary incontinence is a problem characterized by the involuntary loss of urine (Sampselle, Bums, Dougherty, Neuman, Thomas, & Wyman, 1997) that is sufficient to be a problem (U.S. Department of Health and Human Services, 1996). The International Continence Society defines urinary incontinence as the involuntary loss of urine that can be demonstrated objectively and which constitutes a social or hygienic problem. Quality_gfi_Lifig. Negative effects on a person's well— being, especially on daily activities and psychological distress are well documented (Costa, & Mottet, 1997). Assessments of QOL are particularly important as related to urinary incontinence because this problem has little or no 5 impact on mortality, (Jackson, 1997) but impacts significantly on morbidity. QOL is a subjective concept influenced by personal and cultural values, beliefs, self- concepts, goals, age and life expectancy. Several domains that can be measured related to health include physical, emotional and social function, role performance, pain, sleep and disease-specific symptoms (Kelleher et al., 1997). CONCEPTUAL FRAMEWORK Health_2rgm9tign_nodel Pender's model (see Figure 1) was developed to complement health prevention models such as the Health Belief Model developed by Rosenstock, Hochbaum, and Kegeles in the 1950's. The Health Belief Model or Health Protection Model is focused on disease and action specific steps. This model also focuses on efforts to move away from states of illness and injury. Pender's Health Promotion Model (HPM) differs in focus as the goal of health promotion results in growth, maturity, and an expression of human potential. Pender's model initiates action to enhance the quality of human life. Health promotion focuses on efforts to move towards a state of a high-level of health and well being. The Health Promotion Model (HPM) is an approach oriented model. It depicts the multidimensional nature of individuals interacting with their environment as they pursue health (Pender, 1996). The Health Promotion Model is constructed from two theoretical basis; the theory of expectancy-value and social 6 $3. 530% .352 :28...on 5.8: Beacon ._ 82mm 8:233 85:38.55 c583 mcoumo Houses—CE Haggai Al. £39: 6233 $8.8: 3.323209. @0335 L Esme—2&8 .flooa i=8“: All 283203 6.88m f moocoacE .mcoBoEBE Ecofiom 8333 cocoa Co 53 950an a 9 5:35 EocEEEoU “outs c832.§>=o< 8322. o c :ea8 :35 5850.23 Al mum” 805.305 28 333.3 . 9888 So: $582. $509.80 03605.5 cocoa 9 £2.55 nozoeom moococoaxm Ea Al moumtaoeazo 8:8 co 3:222: moEooSO Hanson 3385; 3332.3“ bout/V. n5 82::on oEooamLOSEom cognitive theory. The expected-value theory incorporates ‘ concepts such as how the individual will engage in a specific action if the outcome of the action is of positive personal value and will bring about a desired outcome. Conversely, individuals will not invest their energy if the goal or outcome is of little value to them. Of particular interest to urinary incontinence is the theory of expectancy-value related to this model. As noted in the quality of life inventory studies, incontinent women were frequently dissatisfied with their present situations. According to the HPM theory the subjective value of change is the motivational component driving the individual who is most dissatisfied with their present situation towards favorable change because great rewards or benefits are associated with it. For example, improved continence resulting in decreased isolation, improved self-esteem or resumption of sexual intercourse would have high expectancy value. Social cognitive theory is a broad theoretical approach to explain human behavior and emphasizes the importance of cognitive processes in regulating behavior. Social cognitive theory provides a framework for interaction between the individual and environmental events, personal factors, and behaviors. Self-efficacy is a central construct in the HPM. HPM is similar to the Health Belief model in the belief that predictors of health-promoting behaviors can be 8 categorized into cognitive/perceptual factors (individual perceptions), modifying factors, and variables that affect the likelihood that an individual will take health-promoting action. These actions are the foundation for this theory. Pender believes that these behaviors are driven inner forces as well as external stimuli (Pender, 1996). The model has a decision-making and action phase (see figure 2). According to Pender (1996), health promotion is motivated by the desire to increase ones well being and to actualize human health potential. Assessment of the individual within the context of the HPM expands beyond physical assessment to also include examination of health beliefs and health behaviors. The health promotion model provides a framework to guide this project because women experiencing urinary incontinence utilize a problem-oriented approach to modify their environment, behavior and actions that enhance or alter their quality of life and experiences. Health promotion seeks to expand positive health and well being. This occurs at an individual level and improves one's personal decision making and health practices. Health promotion focuses on efforts to move toward a positive state of high level health and well being. Health promotion strategies effecting individual lifestyle and personal choices made within a social context have powerful influence over women's health prospects related to problems associated with urinary incontinence. Strategies such as modifying risk factors, exercise and diet 9 63— cacao“: 382 530805 5:8: £35m .N oSmE 8.33 comet 3.3: Megfiéfifiooa 8305QO 8238055 988% 8230 ll ”Bocosufi Ecozaafi 232: Honda $8.5: 352.8068 @8255 L _8_wo_onommq f .225 Sng A .3322; ”328.“ .8323 cocoa Co 53 moocoszfi Ecomcom mason—ca a 8 3580925 5:33 EofizfiEoU D $ some vo~a_8-§>:o< 8323 229.8 is Al 3&2 moocoeomoa can 5350.23 SE A—OHHGOU >20: U0>~09~0n~ moan—non masons—.8 25608:: .558 8 E359 32083 moocotoaxm can 23:. AI amfififi moEooSO Hanson 33881 . . 38325 Boob/x can 22::on oEoonmLogaaom 10 can also improve their success of avoiding as well as stopping urinary incontinence. One must note that according to the quality of life inventory studies previously cited, many women with incontinence may have similar or shared experiences. The health care provider can identify these experiences and engage individuals in health promotion. For example, it is common for women with urinary incontinence to not seek health promoting behaviors, thus it is important for the healthcare provider to design interventions to engage the targeted population in these activities. Healthcare providers can assist women in utilizing the health promotion model by assuring opportunities for information exchange and social support among members of this targeted group. This must occur with each and every encounter. This paper will integrate the HPM concepts and focus on these education and intervention opportunities. Assnmplism There are many assumptions of the Health Promotion Model to consider. In order to apply the HPM to women with or potential for urinary incontinence these assumptions must be considered. The following are assumptions of the HBM (Pender, 1996). 0 Individuals desire to create living conditions where they can express their unique health potential. 0 Individuals are self-aware and can assess their own competencies. 11 0 Individuals value positive growth and want to achieve balance between change and stability. 0 Individuals want to regulate their own behavior. 0 Individuals interact with their environment change over time. 0 Health care providers are a part of the individuals interpersonal environment. 0 An individuals self initiated change is critical to behavior change. These assumptions again emphasize the active role an individual takes in pursing health behaviors and in modifying the environmental context for health behaviors (Pender, 1996). They are interdependent and are consistent with the application of social cognitive theory. The primary HPM concepts of concern in developing this project are: 1) Individual characteristics and experiences; 2) behavior-specific cognitions and affect; and 3) behavioral outcomes. These concepts are discussed within the framework of the Health Promotion Model as related to health care behavior. Each person has individual characteristics and past experiences that influence future actions. These include prior related behaviors and many personal factors such as biological, psychological and sociocultural components. Prior related behavior affects the likelihood that an individual will engage in health-promoting behaviors. 12 Pender believes that this is the best predictor of an individual to engage in health-promoting behaviors (Pender, 1996). Personal factors such as age, gender, menopausal status, self esteem, race and ethnicity directly influence cognitions and behaviors, however, many of these factors can not be changed and are not usually incorporated into interventions. E . E J ! 3 E l . According to Pender prior related behavior has both direct and indirect effects on the individuals engaging in health promoting behaviors. An example of direct effects on current behaviors in a women with urinary incontinence is previous habit formation like excessive caffeine intake or use of incontinent pads. Habit strength accrues each time the behavior occurs (Pender, 1996). According to Bandura (1986) the actual enactment of a behavior and its associated feedback is a major source of efficacy or skill information. If positive outcomes are experienced initially the behavior is more likely to be repeated. For example, if an incontinent woman experiences increased continence with the performance of kegal exercises, she may be more likely to maintain a permanent exercise routine in the future. The healthcare provider can help shape the individuals positive behavioral history for the future by assisting to overcome barriers, promoting increased efficacy and providing a positive experience. 13 W As mentioned previously, personal factors can be categorized as biologic, psychologic and sociocultural. In individuals with urinary incontinence it is of particular importance to note personal factors such as age, menopausal status, body mass, self-motivation, perceived health status, education and socioeconomic status. For example a women's educational level directly influences behavior-specific cognitions as well as health-promoting behavior. Behavior-specific cognitions and affect influence an individuals motivational level significantly. This category of variables constitute a center for intervention. Providers have the greatest ability to modify behavior at this level. Individuals decisions about engaging in particular health behaviors are influenced by the perception of what the benefit and/or outcome of the action will be. Beliefs in the benefits or positive outcomes is important for the individual to have in order to engage in a specific health behavior. A woman must believe that improved continence is a benefit and positive outcome in order to engage in healthcare visits and interventions. For example an intrinsic benefit would include improved skin integrity or pelvic floor strength. Perceived extrinsic benefits may include increased social interactions or self-esteem. According to Penter (1996), initially, extrinsic benefits 14 may be more motivational but intrinsic benefits may be more motivation for the long haul. Individuals will engage in health promoting behaviors if positive results are anticipated. I . i E . ! E !° Perceived barriers, imagined or real, affect an individuals ability to engage in health promoting behaviors. If a woman with incontinence is ready to act but perceives that care is not available, treatment options are limited, or the problem isn't significant, the probability of action is low. Conversely, if readiness to act is high and these types of perceived barriers are low, the probability of action is increased. MW As discussed earlier, self-efficacy is a central construct of the HPM. It involves the individuals ability to organize and execute a particular course of action. Self-efficacy involves the ability to judge ones own competence to accomplish a desired Outcome. E l' 'l -E J I 3 EEE ! Pender describes activity-related affect as subjective feelings an individual experiences prior to, during, and following a behavior.‘ These feelings become memories and are associated with subsequent behaviors. The affect associated with the behavior can be positive or negative. (Pender, 1996). Examples of negative feelings are anxiety, fear and depression and positive feeling states as joy, 15 calm, and elation. These feeling are likely to affect whether an individual will repeat the behavior or maintain the behavior long term. Based on social cognitive theory, there is a relationship between self-efficacy and activity- related affect. For example, if a woman experiences feelings of empowerment during and following bladder drilling, this positive affective response influences self- efficacy and the behavior is likely to be repeated. Conversely, if a woman experiences unpleasant feelings during and after bladder drilling due to incontinent accidents, the behavior is not likely to be repeated. MW There are many sources of interpersonal influences on health promoting behaviors. Primary sources include family, friends, peers, and health care providers. Interpersonal influences include norms, social support, and modeling. Individuals like to behave in a way that is consistent with interpersonal influences. For example, if women in a female incontinence support group discussed the benefits of seeking health care for this problem an individual may be influence to adopting this health promotion behavior. 5.! !' ] I E] Situational influences are perceptions that individuals have of a given situation. For example, an individual is likely to engage in health promoting behavior if one perceives the environment that it is occurring in safe and reassuring as opposed to threatening and unsafe. Location 16 of a provider's office, available parking and /or friendly, accommodating staff are examples of situational influences. Behavioral Outcomes : '! I ! E] E E !' Commitment to an action plan is the first step in generating a behavioral event. According to Penner (1996), this commitment implies two underlying cognitive processes: 1) commitment to carry out a specific action at a given time and place and with specified persons or alone, irrespective of competing preferences; and 2) identification of definitive strategies for eliciting, carrying out, and reinforcing the behavior. As these processes imply one must not only have commitment but have strategies as well. Providers can assist the individual in planning to assure successful implementation. For example, if incontinence is noted on health screening interaction the provider can begin the initial educational process and return visit schedule. WW Competing demands and preferences is when an individual chooses an alternative behavior instead of the planned health-promoting behavior. This differs from what is considered barriers to action in that are last minute decisions based on one's preferences that stops the plan for a positive health action or course of action. Self- regulation/control is required to avoid the dilemma to competing demands and preferences. Health care providers can encourage strong commitments to the plan of action. 17 H 1!] E !' E l . Health-promotion behavior is the last step in the process, it is the action outcome. The outcome measure is improved well-being. Since most health-promoting behaviors in a healthy lifestyle are continuing activities integral to daily living, the health care provider must promote acquisition of health-enhancing behaviors and assist individuals in sustaining these behaviors throughout life. In summary, Pender's Health Promotion Model (figure 1) represents cyclical, dynamic interactions between itS‘ components especially between decision making and action. This model synthesizes research findings from nursing, psychology and public health into an explanatory model of health behavior. This model guides the APN in holistic clinical decision making. This holistic approach focuses on the individual and involves a myriad of variables. The Health Promotion Model has application to a wide variety of health-related actions. There is predictive potential that is useful for developing preventive behaviors and intervention plans with women and urinary incontinence. Screening for urinary incontinence and early detection of risk factors are examples of the health promotion model applied to clinical practice. This model enables the APN to exert control in a situation by manipulating or influencing the major variables that are a part of the theory. These factors influenced the 18 decision to use the Health Promotion Model as the framework for this project. LITERATURE REVIEW WWW It is estimated that at least 13 million adult Americans have a problem with urinary incontinence, including approximately 30 percent of community-dwelling persons over 60 years of age (Diokno, Brock, Brown, & Herzog, 1986). For the purpose of this project, literature evaluating community-based women will be reviewed. The Medical, Epidemiologic, and Social Aspects of Aging (MESA) survey conducted by Diokno et al. (1986) reported the prevalence of urinary incontinence in women 60 years and older to be 38%. In this survey, mixed incontinence was most prevalent, at 55.3%, stress incontinence at 26.7%, urge incontinence at 9.1%, and the lother' category at 8.9%. Although urinary incontinence is a common problem, estimates of exact prevalence obtained by epidemiological studies vary considerably. These variations are influenced by several factors, including the way incontinence is defined and the population being investigated. For example, many studies investigate a single urinary symptom such as urinary leakage but do not take into account other symptoms, such as urgency. This produces varied prevalence estimates compared to studies that distinguish between the different types of urinary incontinence, such as in Diokno (1986). 19 Another factor influencing accurate prevalence statistics is the under reporting of urinary incontinence by women to their healthcare provider. Many women think it is an inevitable and/or untreatable problem. Many women feel that it is a normal part of the aging process and have low expectations of benefits in reporting due to perceived limited information regarding treatment options. Many believe nothing can be done (Knapp, 1998). A 1994 study of 104 ambulatory older adults concluded that the majority of adults with urinary incontinence do not report their condition to-their healthcare provider (Burgio, Ives, Locher, Arena, & Kuller, 1994). Currently there is a small body of literature that indicates consistently that many of the individuals who experience incontinence do not seek treatment. A 1991 study completed by Burgio et al., evaluated 541 community based, healthy middle aged women 42 to 50 years old and studied the women twice at three-year intervals. The women were administered a structured incontinence questionnaire by a nurse. Fifty-eight percent of these women reported occasional urine loss and 30.7% reported regular urinary incontinence. This study also concluded that few women seek treatment. Only 25.5% of the women reporting incontinence sought treatment. There was a strong relationship between frequency of urine loss and seeking treatment (chi- square=40.9, p AV $ Eugen Ba .32 =oa~=fi>o 35:: mafia—o 3on 453.38 855385 a a use: 22.3 EoEowafiE 3:5 3:33 ¢ .o @830 Egg 8 0.3.5 gouge 33 ”Roan ._ osmocwsv 855m nos—32m c. as": $253. cogs—«>0 Satan 2:22:85 :zm N 2%: sausage AN 2%.: A mo> 2022.8 0365.5:— ..doEucoo gauge 30.... mix—«£5. 2:39, 3:28.. 23.38 2:892. cozaciaxo iguana. 288 .0353 2a .2 oEab Cocoa gm: .3 E08338 9.632: 5035. cogs—«>0 0.3m .939 335$ 5 8:33:35 335.5 \o 385.3»55‘ 32 basic evaluation if urinary incontinence is identified following the AHCPR guidelines. The purpose in completing all components are to confirm the presence of urinary incontinence, identify contributing factors, identify a presumptive diagnosis, identify individuals appropriate for initial therapy, and to identify individuals who are appropriate for evaluation and referral. All components of the physical exam format are readily available to an ambulatory health care provider. This includes the urine dipstick, post-void residual testing and cough stress test. These tests can typically be done quickly and inexpensively, with minimal equipment. In addition, they do not require complex Clinical Laboratory Improvement Amendments (CLIA certification). However, more advanced assessment such as complex urodynamic testing should be referred to specialty care providers as they are generally considered outside the scope of primary care practice. There are several recommended areas to evaluate prior to using the physical assessment tool. With initial data collection each woman should be asked the urinary incontinence screening questions. If a woman screens positive for urinary incontinence the provider proceeds with the steps of the basic evaluation according to the AHCPR guidelines. The quality of life inventory (Appendices B and C), history and assessment of risk factors is completed and a bladder record (Appendix D), is given to the woman. Steps 33 one through eight of the physical exam checklist (Appendix E) are then implemented. One should reference the AHCPR algorithm for management steps. At any time during the basic evaluation the primary care provider may refer the patient for evaluation by~a specialist. In order to implement the AHCPR guidelines effectively many aspects of urinary incontinence should be reviewed. This includes risk factors associated with urinary incontinence, anatomy and physiology of urinary incontinence, and types of urinary incontinence. This is included in the packet of information for primary care providers (see Appendix F). The physical asseSsment tool is a single sided sheet that provides a format for data collection. Screening data, history, diagnosis and treatment recommendations require documentation elsewhere within the individuals medical record. Screening .Written or verbal screening questions should be provided routinely by the healthcare provider. During an annual physical exam the provider should discuss voiding behavior with women. Language that destigmatizes the condition should be used. The Continence for Women Project, (Sampselle et al., 1997), tested several screening questions, (see Appendix A, partial list) based on the AHCPR 34 guidelines. Asking these key questions can identify individuals who require an evaluation for incontinence. These questions help to differentiate between the two most common types of urinary incontinence in women, stress urinary incontinence and urge urinary incontinence. If screening is positive for urinary incontinence the next step in the AHCPR algorithm is to proceed with the basic evaluation (figure 3). 3151.91): Evaluation of urinary incontinence requires a detailed history. The history should elicit specific information that allows one to categorize and quantify incontinence to optimize treatment choices. It should include a focused medical, neurologic and genitourinary history (Resnick, 1995) as well as assessmentof risk factors, gynecologic history, obstetric history, past medical and surgical history. Review of medications, including nonprescription drugs is imperative (AHCPR, 1996). Many drugs have a direct effect on bladder function or may affect a person's ability to cope with bladder function. For example, diuretics may cause rapid diuresis. Large volumes of urine are produced and may cause increased frequency and urgency. In an already unstable bladder, incontinence may result. Antidepressants/anticholinergic/anti-Parkinsonian/anti- histamine drugs may cause adverse effects on the bladder. These drugs relax the sphincter muscles and reduce smooth 35 muscle contraction, which lead to leakage or high residual of urine. Sedatives/psychotropics may cause confusion and a reduction in mobility, which leads to difficulties in toileting. Alcohol interferes with cognitive function, thus decreasing the ability to control bladder emptying. Alcohol and caffeine stimulate diuresis, leading to frequency and urgency. The primary care provider should explore the subjective symptoms of urinary incontinence. Associated symptoms to explore include: hesitancy, interrupted stream, perineal pain or sensation, straining to void, incomplete emptying, dysuria and factors including the frequency, severity and duration, characteristics (type), pattern (diurinal, nocturnal), alteration in bowel habit/sexual functioning, precipitants of incontinence-(cough, exercise, previous pelvic radiation), fluid pattern, functional assessment(mental status, mobility, living environment, social factors), previous treatments and efficacy, other relevant factors (acute illness, new onset of illness, pelvic or lower urinary tract surgery, chronic illness, neurologic disease), and any bladder record or voiding diary the individual has. A history of bowel habits is important. Chronic constipation and fecal impaction can affect bladder function. Hard, impacted stools can cause outflow obstruction by pressing on the bladder outlet, urethra, and nerves resulting in retention overflow. Direct pressure from impaction and chronic constipation will irritate an 36 already unstable bladder. In addition, the stretching of the pelvic floor can lead to stress incontinence. Symptoms of Stress Incontinence will occur with coughing, laughing, exercising, lifting heavy objects, sneezing, bending and sexual activity. These sudden movements increase intraéabdominal pressure, causing leakage. Symptoms of Urge Incontinence or detrusor instability include urinary frequency, nocturia, and urgency. Symptoms are Caused by the spontaneous and uninhibited detrusor contractions and occur before the bladder is full. Symptoms of Overflow Incontinence include hesitancy, poor stream, post-void dribbling and incomplete emptying caused by an obstruction or an underactive bladder. The individual's history and the history of present illness will help direct the physical examination. For example if the individual complains of urinary incontinence with laughter and reports nothing in her medical or surgical history to suggest the presence of ISD, urethral hypermobility should be suspected and carefully evaluated (Buschbaum & Schmidt, 1993; Ostergard & Bent, 1996). Components of the physical examination should include the following: a general examination, neurologic examination, abdominal examination, pelvic and rectal examination, and initial investigation, (urinalysis, post- void residual, direct observation of urine/cough stress test and laboratory testing). Development of a tool to provide a 37 format for this examination was created for this project (see appendix E). Generallxamination General medical examination is indicated to detect conditions that may contribute to urinary incontinence. Examples include the presence of edema, which may contribute to nocturia or impaired cognition or manual dexterity that affect toileting skills. Confusion, delirium, and disorientation to person, time, place, and environment may lead to the inability to cope with bladder function. Note any loss of cognitive function, tremors, or gait abnormalities that reflect the general neurologic status. Any detected dysfunction should be addressed prior to the initiation of treatment for incontinence. Note the general appearance, attention to personal hygiene and degree of mobility. Included in the general portion of the physical exam is examination of the abdomen. Fundamentals of the exam include checking for diastases recti, organomegaly, masses, and fluid collection. Identification of the superior border of the bladder by palpation and percussion above the pelvic rim to note any tenderness or distention should be included. Assessment of reflexes should be completed. Neurological examination is focused on sacral spine innervation. Abnormal findings such as hyperreflexia of the lower extremities or bladder imply a neurologic disorder such as multiple sclerosis or stroke. 38 E J . E . !° This exam centers around the evaluation of the pelvis and perineal skin. 0 General appearance: assess perineal skin condition for genital atrophy (hypoestrogenism), lesions, excoriation, pelvic muscle laxity at the introital opening, and vaginal discharge. 0 Urethra: note appearance and position of urethral orifice. Inspect for lesions. Palpate for scarring, fibrosis, or tenderness. Presence of a urethral caruncle implies a state of hypoestronenism. Check for urethral hypennobility by the "Q-tip test". -In lithotomy position, place a sterile, lubricated cotton- tipped swab in the urethra to the level of the bladder neck and have the individual cough and strain. Deflection of the Q-tip more that 30 degrees is generally considered abnormal. The primary goal of speculum examination is to obtain a careful evaluation of pelvic support. Evaluation for prolapse is important because frequently pelvic organ prolapse accompanies some types of urinary incontinence. 0 Prolapse Evaluation: This portion of the exam includes inspection of the anterior, posterior, and apical aspects of the vaginal vault. Anatomic abnormalities include cystocele, rectocele, enterocele, and uterine prolapse. The International Continence Society (ICS) 39 has been at the forefront in standardizing the terminology of the lower urinary tract, (Bump et al., 1996). The following clinical description of pelvic organ prolapse is the current standards used in publications and scientific descriptions. During the pelvic examination the primary care provider assigns the prolapse a quantitative description or stage. These stages are assigned according to the most severe portion of the prolapse when the full extent of the protrusion is observed. Stage 0: No prolapse is demonstrated; Stage 1: The most distal portion of the prolapse is > 1 cm above the level of the hymen; Stage 11: The most distal portion of the prolapse is < 1 cm proximal or distal to the plane of the hymen; Stage III: The most distal portion of the prolapse is > 1 cm below the plane of the hymen but protrudes no further than 2 cm less than the total vaginal length in centimeters; Stage IV:.Complete eversion of the total length of the lower genital tract. The distal portion of the prolapse protrudes the total vaginal length. Most of the time the leading edge of the prolapse will be the cervix or vaginal cuff scar. Bimanual examination: The Size of the uterus, Fallopian tubes and ovaries are estimated by palpation. In addition, bimanual exam aSsists in detection of uterine or adnexal masses. The pelvic floor muscles should be assessed for tone, symmetry and motor 40 strength. Pelvic muscle strength is assessed by asking the individual to squeeze her vaginal muscles against the examiner's fingers. The strength is quantified by degree and duration of response (Brink et al., 1994), see figure 4. RectaLExaminatign Several tests of sacral cord integrity are included in the rectal examination. Assess for anal sphincter resting tone and active tone (evidence of intact 82 through S4), anal wink, and perineal sensation. The pudendal nerve, which supplies the external sphincter and the muscles of the pelvic floor and the pelvic nerves, which supply the detrusor, originate from the sacral cord (82 to S4). Resting and active tone is assessed by inserting the finger into the rectum and having the individual squeeze the finger. Anal wink is elicited by stroking the clitoris (bulbocavemosus reflex) or stroking the labia majora. Presence of this reflex suggests an intact autonomic reflux arc. This reflex is present in_70%-80% of neurologically normal women (Rackley & Appell, 1997). Evaluation for presence of tumor, occult blood and fecal impaction should be included. H . 1 . Acute urinary tract infection may lead to transient - sensory urge incontinence with increased frequency and urgency, nocturia and dysuria being present. In addition, urinary tract infection may exacerbate an already 41 2&9 .120 €th 2% mafia 23:2 22$ .Imll. 2: a £583 £538 m A mncooom m v _ A vacuum _ v 282 5 c2839 3:5 28:8 5 3:3 new 3 a: 3:33 commtw 2a 58:85 38:35 o>oE flows: 35:85 058 ecu—a =89? o>oE flowfi 20:3 Co 532 22:5 Amvomab cows—E 282 do Bassoon—ash— 9503 .33 2: =a so: 02.53 638588 costs... sumac ”coats...“ comma mac? coats... Sumac .8 8:288:05 958a >95 2: =m .3an .9525? 3 x2: sumac so 03083 :3 nonunion wcobm so.“ 6333 88032 3 :3 6333 x83 85.8 6283.. 02 2.58.5 V m m _ mMOUm 2QO mafia 28:2 23?— 42 established problem. Rapid dipstick urine evaluation in the ambulatory setting is useful, however, diagnostic tests may have different sensitivities or specificities, (Lachs et al., 1992). In other words, the diagnostic accuracy of these methods vary among different populations and methods. Such conditions as hematuria, glucosuria, pyuria, and bacteriuria can be detected and may cause or be contributing factors in urinary incontinence. If leukocyte esterase and/or bacterial nitrite are detected on rapid dipstick, urine cultures should be obtained. Individuals with infection require treatment. Treatment effects should be observed before further evaluation of urinary incontinence is pursued. E I‘M 'i E .3 1 Post void residual (PVR) measures the amount of urine remaining in the bladder after voiding. This can be measured by straight catheterization or bladder ultrasound. Straight catheterization is a simple an inexpensive procedure and can be done in most primary care offices. A normal PVR is < 50-100 mls. A PVR greater than 100 mls signifies retention. The PVR is useful for differentiating the cause of urinary incontinence. For example, an elevated PVR distinguishes individuals with both incontinence and retention as in overflow incontinence and detrusor hyperactivity with impaired contractility (DHIC) from other types of incontinence. 43 W Cough stress test or provocative stress test is used to confirm the diagnosis of stress incontinence. This direct observation of urine loss is performed with a full bladder. The individual is in the lithotomy position and is asked to cough repeatedly while the provider observes for leakage. If no leakage is observed the test should be repeated in an upright position, (AHCPR, 1996). If strong cough provokes leakage delayed by > than 5 seconds/detrusor instability is likely while instantaneous leakage occurring with cough indicates stress urinary incontinence. Laboratnzx_lssts Baseline testing and evaluation should include lab studies such as blood urea nitrogen (BUN), serum creatinine, electrolytes, and serum glucose (Resnick, 1990). For example, abnormal BUN level may reflect excess fluid consumption. Abnormal BUN, creatinine, glucose and calcium indicates compromised renal function (AHCPR, 1996). Creatinine levels may be helpful for patients with urinary obstruction, noncompliant bladders, or urinary retention. According to the AHCPR guidelines, after the completion of the basic evaluation, initial treatment should be initiated. Many treatment modalities exist for confirmed diagnosis if urinary incontinence. Primary care management generally comprises five basic treatment modalities: 1) the use of behavioral therapy; 2) pharmacologic agents; 3) periurethral injection of bulking agents (collagen); 4) 44 anti-incontinence devices (pessaries); and 5) the use of absorbent products. If individuals are not appropriate candidates for treatment based on presumptive diagnosis or they fail the initial treatments, they should be considered for further evaluation and referral. Implementation The implementation of the physical assessment tool requires distribution to primary care providers and continued evaluation of effectiveness. The tool is used after positive screening for urinary incontinence. It is appropriate to use in cases of stress, urge, mixed, overflow, functional, and transient incontinence. The most effective way to distribute and evaluate the physical assessment tool is by direct mailing to primary care providers in the community. The information packets lead providers through screening, identification and treatment initiation, (see appendix F). The packet and tools will be sent to 25 primary care providers who have referred to the local incontinence clinic for a pilot study. Immediate awareness and implementation of the tool has an effect on women's health care in the community. Follow up with a short telephone survey to evaluate provider acceptance, ease of use, outcomes and feedback including recommendations for change is scheduled for every three months for one year. 45 IMPLICATIONS FOR PRACTICE In promoting a holistic approach to women's health and wellness, APN's can play a key role in the quality of women's lives. Recognizing that urinary incontinence is not normal and dispelling myths associated with urinary incontinence puts nurses at the forefront of promoting continence among women. Taking steps to identify and treat urinary incontinence are essential in primary care practice. By asking questions during routine encounters and by getting women to recognize and talk about their bladder health, nurses can take the first steps toward continence among women. Educating women and helping them to understand that incontinence is never normal is the single most important role related to urinary incontinence the APN can play. In addition, APN have established practices that can offer comprehensive evaluation and treatment options to women with urinary incontinence. The magnitude of the problem allows APNs to take an active role as the front-line assessors and providers of treatment in collaboration with other healthcare professionals. This initial approach will effectively utilize scarce resources without compromising quality of care. Successful diagnosis and treatment of urinary incontinence as part of routine health care is a significant role of APNs. Identification of common medical conditions and medications that cause the problem should be completed 46 by the advanced practice nurse in an effort to reduce the incidence of urinary incontinence. Support efforts should include ongoing patient education and reinforcement of therapy. This type of approach keeps the locus of decision- making between the woman and the primary care provider. APNs are also in an excellent position to work with individuals on behavioral interventions such as pelvic floor exercises, and bladder retraining. APNs can provide education about prevention. Bladder control can be preserved by not over-distending the bladder, a particular problem in occupations (such as nursing) that have limited breaks. Patient education should include encouraging women to establish timed intervals to void to prevent desensitization of the bladder, which can lead to nerve damage. Prevention efforts should include discussion of proper pelvic floor exercise to prevent the onset of stress incontinence. An APN should also continue to increase public awareness of the prevention of urinary incontinence through modification of known risk factors. By following the Agency for Health Care Policy and Research guidelines and utilizing the physical exam format proposed in this project the primary care provider will assure assessment of all key areas of incontinence (AHCPR, 1996). The physical exam format promotes identification and cues of differentiation of types of urinary incontinence. It is this authors hope for the future that all women seeking general health care are screened for urinary 47 incontinence and for those who screen positive to receive a basic evaluation using this physical exam tool. Outcomes for women with urinary incontinence can be measured by improved quality of life. IMPLICATIONS FOR RESEARCH Opportunities for APNs in health promotion are vast. Advanced practice nurses need to take a leadership role in incontinence research and research utilization. Advanced practice nurses need to use the research base that exists and promote the development of new research. Nursing practice needs to be research based, not only to provide quality care, but to insure that nursing as a profession continues to grow. It is apparent in the literature that gaps of current scientific information exist in the arena of female urinary incontinence, however, increased awareness by both providers and consumers will stimulate future research questions to be conducted by APNs. In addition, APNs can play a role in creating partnerships among scientist, practitioners and consumers to develop appropriate care strategies for women with urinary incontinence. For example, research of strategies to help individuals regain continence need to continue to be developed, investigated, evaluated, and utilized by APNs in primary care. The Continence for Women Research Utilization Project (Sampselle et al., 1997) is an excellent example of nurses involved in developing, implementing, and evaluating data on female incontinence. Examples of areas requiring immediate nursing 48 research include clinical research on prevention, diagnosis and treatment, especially behavioral treatment modalities and research into the costs of diagnosis and treatment of urinary incontinence, especially care provided by advanced practice nurses. A potential extension of this project would be to integrate the utilization of this tool into a large managed care organization. One could look at billing information for diagnosis and referrals pre-intervention. The educational intervention for the organizations primary care providers would include review of the information packet and tools and AHCPR management guidelines for incontinence. One would follow up by looking at post implementation data. IMPLICATIONS FOR PROFESSIONAL EDUCATION As outlined in the AHCPR guidelines there are focused areas to improve professional education related to urinary incontinence. Recommendations to include the study of urinary incontinence in undergraduate and graduate core curricula in all health care programs is the first step to improve the identification and management of urinary incontinence. According to the AHCPR committee, practical applications and demonstrations of how urinary incontinence is identified and managed in primary care would positively augment the curricula. Provision of comprehensive continuing education courses focused on urinary incontinence should be available for all primary care providers. Presentations at area conferences 49 or programs directed by primary care providers, especially advanced practice nurses should be included in an educational plan. SUMMARY Urinary incontinence is a prevalent, underreported and undertreated problem associated with significant healthcare costs, substantial socioeconomic burden, and related health and psychological concerns. The AHCPR guidelines contain the most current comprehensive algorithm for the management of urinary incontinence in primary care. This algorithm provides a visual display of the conceptual organization, procedural flow, decision points, and preferred management pathways. This project provides a tool to implement the basic evaluation in this algorithm. The primary goal of the AHCPR guidelines is to improve education, detection, evaluation, and management of urinary incontinence. This project contributes to the attainment of these goals. 50 APPENDIX A SCREENING QUESTIONS 1. Do you ever leak urine/water when you don’t 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 every use pads, tissue, or cloth in your underwear to catch urine? Adapted from: Sampselle et al, 1997 51 APPENDIX B Short forms to assess life quality and symptom distress for urinary incontinence in women: The Incontinence Impact Questionnaire and the Urogenital Distress Inventory. Incontinence Impact Questionnaire Short Form (HQ-7) Has urine leakage and/or prolapse affected: Household chores Physical recreation Entertainment activities Travel > 30 minutes away from home Social activities Emotional health (nervouseness, depression, etc.) Feeling frustrated 89999591“ Urogenital Distress Inventory Short Form (UDI-6) Do you experience, and if so, how much are you bothered by: Frequent urination Leakage related to feeling of urgency Leakage related to activity, coughing, or sneezing Small amounts of leakage (drops) Difficulty emptying bladder Pain or discomfort in lower abdominal or genital area P‘MPS’JNT‘ Adapted from: Incontinence Impact Questionnaire and Urogenital Distress Inventory Long Forms (Shumaker et al., 1994) 52 APPENDIX C FEMALE INCONTINENCE HISTORY FORM Date: / / Patient Name: Allergies: Date of Birth: / / History of Present Illness Current Medications (Including non prescription drugs) Family History I i B Pressure Diabetes Heart Disease Disease ! Social History I ‘ ()S ()W ) 0 Yes ()N0( 68. t ( ) N0 ( ) es, ( No ) es, active( ) No ( ) Yes, ( ) Men ( ) Women ( ) 53 l 1. Past Medical History | ' Hi B Pressure Heart Disease Lun Disease K' Disease H Past Surgical History ‘ Obstetrical History l Number of Pregnancies:___ Number of Vaginal Births: Weight of Largest Child: Any history of trauma/lacerations( )No ( ) Yes Describe: Gynecological History ‘ _ _l Are you still having menses (periods)? ( ) Yes ( )No If Yes: How Often? Any bleeding between menses? ( ) Yes ( ) No In No: Age when menses stopped? Do you use prescription Estrogen? ( ) Yes ( )No If Yes: Name: Dose: Do you use any non-prescription sources of Estrogen? ( ) Yes ( ) No If Yes: Name: Dose: Are you sexually active? If yes are you experiencing any problems? 54 Bowel Function Review ! Unence of Im Functional Assessment Mental status Mobility Living environment Urologic Review of ystems Stress incontinence actiVity? U Incontinence ? ( Hematuria UTl recurrent HeSItation P ptying stream Strain' to void rinary reatment: u Pattern or sensation Ev Descri reatment Descri Descri 55 APPENDIX D NAME: DATE: INSTRUCTIONS: Place a check in the appropriate column next to the time you urinated in the toilet or when an incontinence episode occurred. Note the reason for the incontinence and describe your liquid intake (for example: coffee, water, etc.) and estimate the amount (for example: one cup). Time interval Urinated in toilet Had a small incontinence episode Had a large incontinence episode Reason for incontinence episode Type/amount of liquid intake 6-8 am. 8-10 am. lO-noon Noon-2 p.m. 2-4 pm. 4-6 pm. 6-8 pm. 8-10 pm. 10-midnight Overnight No. of pads used today: No. of episodes: Comments: Source: Agency for Health Care Policy and Research Clinical Practice Guidelines, 1996. 56 APPENDIX E FEMALE INCONTINENCE PHYSICAL EXAM CHECKLIST Height: Weight: Blood Pressure: / Pulse: Respiration: 1. Mental Status Normal Abnormal 0 Date 0 Reason for visit 0 Person 2. Gait Normal Abnormal o Symmetiy o Stance 3. General Examination — WNL Appearance Skin HEENT Thyroid Heart Lungs Breasts Nodes Abdomen Extremities Reflexes Other Yes No 4. Gynecological Exam — WNL Ext. Genitalia Uterus Uretha Adnexa Vagina Rectum Cervix Anal wink Yes No S. Prolapse Stage: 0 I II III IV Yes No 6. Cough Stress Test Yes No 7. Dipstick Urinalysis — WNL 0 Positive for nitrites 0 Treatment initiated 0 Presence of glycosuria, hematuria, or proteinuria Yes No 8. Post Void Residual Urine (PVR) 0 Amount 0 If > 100 ml referred for further evaluation Developed by: Michelle F edewa 4/00 57 APPENDIX F Dear Primary Care Provider, As you are aware, female urinary incontinence is a prevalent health care issue that affects a significant proportion of an otherwise healthy population. This condition is associated with significant impact on aspects of life for many women. As a primary care provider you have the opportunity to identify urinary incontinence and to initiate interventions to decrease urinary symptoms and improve women’s quality of life. Enclosed you will find a packet of information that includes a short review of urinary incontinence and tools to assist you in utilizing the Agency for Health Care Policy and Research Guidelines on Urinary Incontinence in Ambulatory Care. The packet includes screening questions that can be incorporated in an initial database and a short inventory for assessment of QOL and symptom distress. This can be administered at the initial visit and at future visits to evaluate outcomes. A female incontinence history inventory and physical exam checklist are also provided. These tools assist in systematically collecting this data. I am interested in your feedback. I will be contacting you for your comments at three-month intervals for 12 months. If you have questions, comments or proposed changes before then please do not hesitate to call me. Thank you for contributing to quality healthcare for women in our community. Sincerely, Michelle Fedewa, RNC, MSN 58 APPENDIX G 090.... Risk factors associated with incontinence Anatomy and Physiology Types of urinary incontinence Screening questions Quality of life inventory Bladder record Female incontinence history form (developed by Michelle Fedewa, R.N., M.S.N.) Female incontinence physical exam checklist (developed by Michelle Fewewa, R.N., M.S.N.) Pelvic Muscle Rating Scale 59 E' I E l i ! I W] !' Although the etiology of urinary incontinence is often unknown, several factors influence the incidence of urinary incontinence. As previously stated, female gender ad age are risk factors. The prevalence increases with advancing age, which is the most common factor associated with urinary incontinence. It is important to note that aging alone does not cause urinary incontinence. Numerous age related and age associated factors can potentially affect the lower urinary tract, thus contributing to or causing lower urinary tract symptoms. Age related refers to those factors that change with aging in the absence of clearly defined pathologic conditions. An example of age related changes that may effect urinary function in women is the decline in estrogen levels. Multiparity, smoking, obesity, and connective tissue changes also appear to influence this problem. The prevalence of stress incontinence is greater in multiparous women. In women 15 to 64 years old, urinary incontinence is more common than nulliparous women (Jolleys, 1989). According to Jolleys, increased prevalence is also associated with perineal suturing after childbirth, due to damage of the pelvic floor following vaginal delivery. Changes in the connective tissue surrounding the bladder neck may be a risk factor for stress incontinence, particularly in young women who have never had children. Some studies conclude that changes include abnormal cross- 60 linking of collagen fibers, changes in the thickness of collagen fibers, and overall reduction in total collagen compared with continence controls. Smoking may cause damage to the urethra and supporting structures from chronic coughing, alteration in the synthesis and quality of collagen or increased stimulation of bladder contractions from nicotine. In addition, the anti-estrogen effects of smoking may affect continence, (Bump et al., 1992). Obesity is thought to impact urinary incontinence. Despite reports of improved urine control associated with weight loss, the effectiveness of weight loss as an intervention needs to be tested. Currently, no conclusive studies are available related to this issue, however, a study by Dwyer et a1. (1998) reported that a body mass index of more than 20% above the mean body mass index for age is more common in women with urge incontinence or stress incontinence than women in the normal population. No difference in urodynamic variables, however, was found between obese and non-obese incontinent women in his study. A number of medications are associated with side effects that can increase risk for urinary problems or contribute to existing problems. As will be discussed further with Transient Incontinence, anticholinergic agents are known to cause urinary retention, overflow incontinence, and impaction. Many psychotropic medications, such as antidepressants and antipsychotics are associated with 61 anticholinergic actions such as dry mouth, urinary retention, and sedation. Further, a-adrenergic blockers, a- adrenergic agonists, b-adrenergic agonists, and calcium channel blockers have the potential to cause urinary retention. Women taking drugs in these classifications should be closely monitored for urinary retention, particularly elderly women. Additional drugs associated with urinary side effects include: diuretics (polyuria, frequency, and urgency) and alcohol (polyuria, frequency, urgency). Winslow Urinary incontinence is a problem not a disease of the lower urinary tract. It is a sign of an underlying condition. The lower urinary tract is comprised of the bladder, urethra, and supporting muscles and ligaments, (Aydelotte & Wilson, p. 12, in Buchsbaum & Schmidt, 1993). Each structure plays a role in the storage and evacuation of urine. Problems with normal functions of the bladder, urethra, spinal cord or brain results in incontinence. The exact nature of the incontinence is known from the examination and evaluation of these structures. Understanding the anatomy and physiology of the entire lower urinary tract is important for understanding the dysfunctions, however, in women, continence is mainly controlled by the urethra and the ureterovesical junction. The bladder is a hollow sac of muscular and connective tissue that stores urine produced by the kidneys. The wall 62 of the bladder is formed predominately from the detrusor muscle, which is the main contractile element of the bladder. The bladder is also comprised of trigonal muscle, which is thought to play a role in closure of the urethra. The bladder relaxes during the filling phase and contracts during the emptying phase, (Delancy p. 12, in Ostergard & Brent, 1996). During the filling phase of the bladder sympathetic stimulation of beta-adrenergic receptors in the bladder wall cause detrusor relaxation. In addition, parasympathetic activity is inhibited by this sympathetic stimulation encouraging further relaxation of the smooth muscle facilitating bladder emptying. This relaxation is responsible for the bladder's ability to hold increasing amounts of urine. Once the bladder reaches its capacity the receptors within the detrusor muscle signals the brain to initiate voiding. If this normal function is compromised the result is urge urinary incontinence or detrusor instability. The urethra is a hollow tube that carries urine away from the bladder to be voided. The urethra works in the opposite manner than the bladder, in that it contracts during filling and relaxes during emptying. During the filling phase sympathetic stimulation causes urethral contraction and increased urethral pressures. There are three systems that are necessary for urethral closure, which is a key component if continence. First, the internal sphincter provides continuous involuntary contraction of the 63 muscles and keeps the urethra closed except during voiding. It is found at the junction of the bladder and the urethra. Secondly, the flow of urine through the urethra is controlled by the external sphincter, (Delancy, in Ostergard & Brent, p.5). This sphincter is voluntarily controlled as assists to prevent unintentional emptying by countering the effects of increased intraabdominal pressure. In order to void the pudendal and sacralnerves innervating this area must relax. The final component is an arteriovenous complex called the submucosal vasculature. This maintains a watertight mucosal seal and maintains the urethral resting pressure, (Delancy in Ostergard & Brent, p 8). These structures are estrogen dependent. Lack of estrogen leads to atrophy of the urethral mucousal lining and vascular cushion. The supporting muscles, ligaments and connective tissue of the pelvic floor provide the foundation for the bladder and the urethra. Without this foundation the lower urinary tract will not function optimally (Delancy, in Ostergard & Brent, p. 10). These components maintain the proper position of the ureterovesical junction and urethra within the pelvis. These muscles are in a constant state of contraction and contract even more with increased intrabdominal pressure like when one coughs, sneezes or laughs. In summary normally as urine fills the bladder the detrusor accommodates this by stretching and thinning 64 without increasing internal pressure. The bladder wall then activates receptors and the parasympathetic response that causes the detrusor to contract and the internal sphincter to relax. Impulses are transmitted to the brain producing a feeling of bladder fullness. When the external sphincter voluntarily relaxes, emptying of the bladder occurs. W There are several types of urinary incontinence. Most can be categorized as either a failure to store urine or empty urine. A disruption of either of these functions can occur at the level of the bladder, urethra, spinal cord, or brain. Developmental problems with bladder or urethral closure in embryogenesis or a congenital ectopic uterus may cause primary incontinence. It is important to elicit information on the history to differentiate between this type of primary (lifelong) incontinence or acquired incontinence, (Lawson, Russell, Taylor, Andrew in Bushsbaum & Schmidt 1993, p. 77). There are several different types of acquired urinary incontinence. Classification of urinary incontinence groups include: stress urinary incontinence, urge urinary incontinence, reflex urinary incontinence, overflow incontinence and functional incontinence (National Institutes of Health, 1988). Most incontinence is a result of the inability to store urine or a failure to empty urine. STRESS URINARY INCONTINENCE Stress urinary incontinence or Genuine Stress Incontinence is defined as the involuntary loss of urine 65 that occurs with a sudden increase in intraabdominal pressure in the absence of detrusor activity. Intravesical pressure exceeds urethral closure pressure in such activities as laughing, coughing, sneezing, bending, lifting heavy objects or other physical activities resulting in the leaking of urine (AHCPR, 1996; Haeffier & Morley, 1998; Wehle & Petrou, 1999; Neuman, Lynch, Smith, & Cell, 1991; Resnick, 1995). Intrinsic urethral sphincter deficiency (sphincter incompetence or ISD) may result from damage to the proximal urethra due to congenital sphincter weakness, multiple surgeries, trauma, radiation, neurogenic disorders, or hypoestrogenism. The urethra becomes rigid and unable to contract and function properly. It is unable to provide sufficient resistance in the bladder to prevent urine loss, (AHCPR, 1996; Rackley & Appell, 1997). Urethral hypermobility or anatomic incontinence is the malposition and displacement of the urethra and bladder neck caused from anterior wall relaxation, (AHCPR, 1996; Weinberger, in Ostergard and Bent, 1996, p. 84-84, Rackley & Appell, 1997). This is a loss of anatomic support of the urethra, bladder and ureterovesical junction. This accounts for 90% to 95% of stress incontinence, (Juma, Little & Shlomo in Bushsbaum & Schmitdt, 1993, p. 251-255). There is a defect in the pelvic support of the ureterovesical junction. The urethra and bladder neck are displaced to such a degree the proximal urethra is outside the abdominal pressure zone and when intraabdominal pressures increases, 66 incontinence occurs. This is a result of neuromuscular damage of childbirth, aging, trauma, spinal cord lesions, hypoestrogenism, or prior surgeries (AHCPR, 1996; Juma, Little, & Raz, in Bauchsbaum & Schmidt, 1993, p. 251-255; Summitt & Bent in Ostergard & Bent, 1996 p. 493-495; Rackley & Appell, 1997). URGE URINARY INCONTINENCE Urge incontinence is the involuntary loss of urine as a result of involuntary bladder contractions associated with a strong desire to void that occurs during the storage phase of the micturition cycle. As previously mentioned, it is characterized by detrusor instability (DI) attributed to involuntary detrusor contractions or detrusor overactivity. (Montella, 1996, in Ostergard & Bent p. 465-466; AHCPR, 1996; Rackley & Appell, 1997). This is usually an idiopathic condition. When there is a known neurologic cause for this bladder overactivity such as with multiple sclerosis, cerebrovascular accidents, spinal cord injury, ataxia, brain tumor or Parkinson's disease this is called detrusor hyperreflexia. In addition, there are variants of urge incontinence. Reflex incontinence is an involuntary loss of urine from detrusor contraction but with no feeling of urgency and detrusor hyperactivity is impaired bladder contractility (DHIC) seen in the frail elderly. These involuntary detrusor contractions cause incontinence but the bladder does not completely empty. 67 Detrusor instability (DI) can be objectively defined on cystometry as an involuntary detrusor contraction equal to greater than 15 cm H20. It is most prevalent in the elderly. According to Montella (1996), detrusor instability occurs in 5%-10% of premenopausal patients and increases to 38% in the elderly. The clinical presentation includes frequency, urgency, urge incontinence and nocturia. DI is commonly found with stress incontinence also. MIXED URINARY INCONTINENCE Mixed incontinence is defined as a combination of different types of incontinence (AHCPR, 1996; Rackley & Appell, 1997; Weinberger, 1996, p. 85). There are other combinations of mixed incontinence but urge and stress are the most common. According to Rackley and Appell (1997) between 50% and 60% of those with stress incontinence also have urge incontinence also have urge incontinence. The degree to which each component contributes to the presenting incontinence varies but generally one factor predominates. Patients with mixed incontinence leak large volumes of urine and tend to have more incontinent episodes per week than with stress incontinence or urge incontinence (Fantl, Bump, & McClish, 1990). It is important to recognize and evaluate each anatomic and neurological component to distinguish incontinence types. OVERFLOW INCONTINENCE Overflow incontinence is characterized by an over- distention of the bladder associated with the involuntary 68 loss of urine and abnormal voiding patterns. The bladder capacity is exceeded and urine leaks through the urethra. It is usually seen in the elderly and neurologically impaired. Usually this type of incontinence is caused by outflow tract obstruction or detrusor under activity or acontractility. Outflow tract obstruction is uncommon in women, however, it can occur in conditions of pelvic prolapse, uterine fibroids, ovarian neoplasms, and acutely retroverted uteri. Detrusor under activity is seen in such conditions as diabetes (peripheral neuropathy), multiple sclerosis, Vitamin B12 deficiencies, spinal cord and central nervous system injuries or herniated disks. There are also numerous medications that stimulate overflow incontinence, anticholinergics, calcium channel blockers, alpha- and beta- agonists, and diuretics. Symptoms of overflow incontinence include complaints of unconscious intermittent or constant dribbling of urine. Complaints of hesitancy, the necessity to bend or lean over to void or to use suprapubic pressure are common. FUNCTIONAL INCONTINENCE Functional incontinence is the involuntary loss of urine as a result of immobility or cognitive impairment in the presence of a normally functioning lower urinary tract. Diagnosis of this condition is one of exclusion Environmental factors may impair ones ability to reach the facilities before incontinence occurs. Correcting environmental factors like inaccessible facilities, 69 unfamiliar surrounding or physical restraints may impact the problem. In addition, musculoskeletal conditions (arthritis) that involve ambulation and dexterity are factors that may contribute to functional incontinence. Medications like long acting sedatives alter mental status and may result in involuntary loss of urine. Urinary incontinence can often be improved or cured by improving the functional status, treating other medical conditions, discontinuing certain medications, or adjusting hydration status. TRANSIENT INCONTINENCE There are many factors that need to be evaluated when considering and differentiating the diagnosis of incontinence. Transient or reversible causes of incontinence have an acute onset and are common in the elderly and hospitalized population. Resnick developed the neumonic "DIAPERS" to categorize the causes of transient incontinence, (Resnick, 1995). According to Resnick (1995), transient incontinence may account for up to one third of community dwelling incontinence. This type of incontinence resolves once the precipitant is reversed. D-delirium or confessional state I-infection, urinary (symptomatic) A-atrophic vaginitis or urethritis P-pharmaceuticals, drug side effects and psychological disorders E-endocrine disorder (hypercalcemia, hyperglycemia) R-restricted mobility S-stool impaction 70 SCREENING QUESTIONS 1. Do you ever leak urine/water when you don’t 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 every use pads, tissue, or cloth in your underwear to catch urine? Adapted from: Sampselle et al, 1997 71 Short forms to assess life quality and symptom distress for urinary incontinence in women: The Incontinence Impact Questionnaire and the Urogenital Distress Inventory. Incontinence Impact Questionnaire Short Form (HQ-7) Has urine leakage and/or prolapse affected: Household chores Physical recreation Entertainment activities Travel > 30 minutes away fiom home Social activities Emotional health (nervouseness, depression, etc.) Feeling fi'ustrated sewswwr Urogenital Distress Inventory Short Form (UDI-6) Do you experience, and if so, how much are you bothered by: 1. Frequent urination 2. Leakage related to feeling of urgency 3. Leakage related to activity, coughing, or sneezing 4. Small amounts of leakage (drops) 5. Difficulty emptying bladder 6. Pain or discomfort in lower abdominal or genital area Adapted from: Incontinence Impact Questionnaire and Urogenital Distress Inventory Long Forms (Shumaker et al., 1994) 72 FEMALE INCONTINENCE HISTORY FORM Date: / / Patient Name: Allergies: - Date of Birth: / / ‘ History of Present Illness % Current Medications . | l (Including non prescription l drugs) Family History H eart Lun Disease Social History .i l (l ()S )W es No es, es, ( 68. l active( ) No ( Yes, ( ) Men ( ) Women ( ) 73 Past Medical History . ‘ Past Surgical History i i L_____; ' Obstetrical History if . ' 5' O Number of Pregnancies:_ Number of Vaginal Births: Weight of Largest Child: Any history of trauma/lacerations( )No ( ) Yes Describe: Gynecological History Are you still having menses (periods)? ( )Yes ( )No If Yes: How Often? Any bleeding between menses? ( ) Yes ( ) No In No: Age when menses stopped? Do you use prescription Estrogen? ( ) Yes ( )No If Yes: Name: Dose: Do you use any non-prescription sources of Estrogen?( ) Yes ( ) No If Yes: Name: Dose: Are you sexually active? If yes are you experiencing any problems? 74 Bowel Function Review is i Mental status Mobility Living environment [‘0 Stress incontinence recurrent stream ° to void reatment: Pattern reatment 75 NAME: DATE: INSTRUCTIONS: Place a check in the appropriate column next to the time you urinated in the toilet or when an incontinence episode occurred. Note the reason for the incontinence and describe your liquid intake (for example: coffee, water, etc.) and estimate the amount (for example: one cup). Time interval Urinated in toilet Had a small incontinence episode Had a large incontinence episode Reason for incontinence episode Type/amount of liquid intake 6-8 am. 8-10 am. lO-noon Noon-2 p.m. 2—4 pm. 4-6 pm. 6-8 pm. 8-10 pm. lO-midnight Overnight Li No. of pads used today: Comments: No. of episodes: Source: Agency for Health Care Policy and Research Clinical Practice Guidelines, 1 996. 76 FEMALE INCONTINENCE PHYSICAL EXAM CHECKLIST Height: Weight: Blood Pressure: / Pulse: Respiration: 1. Mental Status Normal Abnormal 0 Date 0 Reason for visit 0 Person 2 Gait . Normal Abnormal 0 Symmetry o Stance 3. General Examination—WNL Appearance Skin HEENT Thyroid Heart Lungs Breasts Nodes Abdomen Extremities Reflexes Other Yes ' No 4. Gynecological Exam - WNL Ext. Genitalia Uterus Uretha Adnexa Vagina Rectum Cervix Anal wink Yes No 5. Prolapse Stage: 0 I II III IV Yes N o 6. Cough Stress Test Yes Nb 7. Dipstick Urinalysis — WNL 0 Positive for nitrites 0 Treatment initiated 0 Presence of glycosuria, hematuria, or proteinuria Yes No 8. Post Void Residual Urine (PVR) 0 Amount 0 If > 100 ml referred for further evaluation Developed by: Michelle Fedewa 4/00 77 Dear Primary Care Provider, As you are aware, female urinary incontinence is a prevalent health care issue that affects a significant proportion of an otherwise healthy population. This condition is associated with significant impact on aspects of life for many women. As a primary care provider you have the opportunity to identify urinary incontinence and to initiate interventions to decrease urinary symptoms and improve women’s quality of life. Enclosed you will find a packet of information that includes a short review of urinary incontinence and tools to assist you in utilizing the Agency for Health Care Policy and Research Guidelines on Urinary Incontinence in Ambulatory Care. The packet includes screening questions that can be incorporated in an initial . database and a short inventory for assessment of QOL and symptom distress. This can be administered at the initial visit and at future visits to evaluate outcomes. A female incontinence history inventory and physical exam checklist are also provided. These tools assist in systematically collecting this data. I I am interested in your feedback. I will be contacting you for your comments at three-month intervals for 12 months. If you have questions, comments or proposed changes before then please do not hesitate to call me. Thank you for contributing to quality healthcare for women in our community. Sincerely, Michelle Fedewa, RNC, MSN 78 REFERENCES Buchsbaum, H., & Schmidt, J. (1993). fixnegglggig_and Quatetzig_urglggy. Philadelphia, PA: W.B. Saunders Company. Ostergard, D., & Bent, A. (1996). W W Baltimore. MD: Williams & Wilkins. 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