Urinary incontinence
  • Woman and men sometimes wet themselves because they can't control when they pass urine
  • Often ashamed and don't ask for help
  • More common in women who have had children. Often gets worse as woman gets older, if overweight or has urinary tract infection
  • Many causes and some serious
  • Absorbent pads/continence aids are not treatments. Can help with symptoms but underlying cause needs to be addressed

Ask

  • When did the problem start
  • When does urine come out
    • All the time (dribbling)
    • Before they can get to toilet (can they hold on/urgency)
    • When they 'strain' (cough, sneeze, lift, laugh)
    • Do they wet the bed
  • Do they know when it is coming out
  • How many times do they go to toilet each day and at night
    • How much comes out each time — small or large amount
    • Does bladder empty completely, is it hard to pass urine or do they dribble afterwards
  • Do they wear pads or similar
  • Any other urine problems — pain, burning
  • Is there lump coming out of vagina, or feeling of dragging/pulling — see Pelvic organ prolapse
  • How much fluid do they drink — ask about alcohol, coffee, tea, soft drink
  • Pregnant
  • If postmenopausal (stopped having periods)
  • Any change in bowel habit (eg constipation, leakage)

Check

  • Check file notes for risk factors
    • Obstetric and gynaecological history — fibroid uterus, prolapse, menopause, birth weight history, forceps deliveries, obstetric anal sphincter injury
    • Medical history — diabetes, kidney disease, COPD, medicines
  • Calculate REWS — AVPU, RR, O2 sats, pulse, BP, Temp
  • Weight, BGL 
  • U/A, pregnancy test
  • If skilled
    • Check for big bladder, pelvic masses, fistula, prolapse
    • Check pelvic floor muscles — does urine leak during check, when woman coughs or bears down
  • If not skilled but have concerns — medical consult

Do

  • Urine for MC&S even if U/A normal
  • Screen for diabetes if not done in last 12 months
  • Teach pelvic floor exercises or refer to physio
    • If no improvement after 10 x 10 second holds for 3 months — medical consult

Medical consult  for 

  • Renal tract ultrasound to check for urinary residual volume (incomplete emptying of bladder) may need to travel to major centre
  • Assessment of bladder and urethra 
  • Gynaecologist review — may recommend
    • Topical hormone (oestrogen) therapy 
    • Medicine to reduce urinary urgency
    • Surgery to stop leakage

Treat co-existing conditions

  • If UTI — treat
  • If diabetes — better control of blood glucose may improve symptoms
  • If constipation
    • Talk about how she sits on toilet. Suggest sitting with knees higher than hips, may use footstool or squat toilet
    • Avoid pushing/straining
    • Consider referral to dietitian

Talk about

  • Possible causes. Reassure them incontinence is reasonably common and treatment is available
  • Reducing pressure on weak pelvic floor
  • Drink more water if urine is dark
  • Avoiding drinks that make her go to toilet more often (eg coffee, tea, soft drink) — try to limit to total of 3 a day
  • Keeping urine volume and frequency chart for a few days
    • Tracks what she is drinking, how much/often urine passed
    • Standard charts available from continence advisor

Pelvic organ prolapse

Muscles and fascia supporting the bladder, uterus and bowel can be weakened or torn. Pelvic organ (bladder, uterus or bowel) protrudes into or out of vagina — Figure 6.20

Figure 6.20     

Ask

  • If feels lump in vagina
  • Pulling/dragging feeling in vagina
  • Leaking urine, difficulty passing urine
  • Constipation
  • Painful sexual intercourse

Check

  • If skilled — check when woman coughs or bears down
    • Does front/back vaginal wall appear as a lump at opening of vagina
    • Does urine leak
    • If cervix is coming out of vagina — severe pelvic organ prolapse

Do

  • Urine for MC&S even if U/A normal
  •  Gynaecologist referal for of  all women with any symptoms of pelvic organ prolapse for full assessment and discussion of treatment options
  • If UTI — treat
    • Do medical follow-up MC&S to check infection has cleared

Supporting resources

  • Continence Foundation of Australia website
  • Female incontinence educational video