This Self-Learning Portal provides information about post-stroke urinary continence challenges and evidence-based urinary continence management options.

The learning modules should take approximately 1 – 3 hours of your time and may be completed at your discretion:

Module 1: Stroke & Continence [15 minutes]

Module 2: Urinary Continence Assessment Recommendations [15 minutes]

Module 3: Urinary Incontinence Management Recommendations [10-15 minutes]

Module 4: Urinary Retention Management Recommendations [10-15 minutes]

Module 5: General Continence Management Recommendations [5 minutes]

Module 6: Review Continence Care Recommendations [5-10 minutes]

Module 7: Learning Assessment [5-10 minutes]

You can access supplementary resources (e.g.: PowerPoint presentations, assessment tools, protocols, etc.) in the Documents section.  Upon successful completion of the knowledge test and learning evaluation, you will receive a certificate of completion.

We greatly value your expertise and look forward to implementing the Clinical Practice Guidelines for the Urinary Continence Management of Stroke Survivors in Acute and Rehabilitation Settings with you.

Continence Nursing and Post-Stroke Urinary Continence Challenges

Continence nursing is an advanced specialist role that is fulfilling because it allows you to assume a leadership role in patient care and greatly improve patient well-being. In the video below, an Australian continence nurse, Fran, discusses her experiences working in a nurse-initiated clinic specializing in the diagnosis and management of urinary incontinence.

Many patients, as Fran notes, are embarrassed by continence challenges. Many individuals feel too embarrassed to seek treatment, although treatment and management options may help to reduce the occurrence of incontinent episodes. This may be in part due to many of the myths associated with urinary continence care, such as the following:

• Urinary continence is a natural part of the aging process;
• Nothing can be done to effectively manage and resolve urinary continence challenges; and,
• Urinary continence challenges do not happen to otherwise healthy people.

Nurses have a great opportunity to improve patient well-being by demystifying and addressing urinary continence challenges. This is especially important for stroke survivors due to the high prevalence of urinary continence challenges among this patient population.

The National Sentinel Stroke Audit reports that 44% of stroke survivors suffer from urinary incontinence at one week post-event (Royal College of Physicians, 2002). The impact of urinary incontinence on stroke survivors has been shown to have an adverse affect on stroke survival, disability and institutionalization rates (Devroey et al, 2003; Patel et al., 2001). A previous study has reported that 29% of stroke survivors experience urinary retention (Kong, 2000). Managing stroke survivors’ urinary continence challenges is a key way to prevent complications such as skin breakdown and urinary tract infections, which may result in prolonged hospital stays.

How the Bladder Works

The video below provides an overview of the micturition reflex, the process of expelling urine from the bladder.

Urinary incontinence is the involuntary loss of urine resulting from a loss of bladder and/or sphincter control (RNAO, 2005). Stroke survivors may experience any one of several types of urinary incontinence.  Urinary incontinence may be a complication of stroke or it may be due to a previous condition. Better understanding the types of urinary incontinence listed below may help with diagnosis and management:

• Transient incontinence: This is the involuntary loss of urine due to outside factors affecting bladder management, such as medications, vaginitis, urethritis, and constipation (RNAO, 2005).
• Urge Incontinence: Involuntary loss of urine after feeling the sudden urge to void (RNAO, 2005).
• Stress Incontinence: Involuntary loss of urine due to an increase in intraabdominal pressure, which occur when sneezing, coughing, or other movements (RNAO, 2005; Skelly, 2007).
• Mixed Incontinence: Loss of urine displaying the characteristics of both urge and stress incontinence (RNAO, 2005).
• Overflow incontinence: Involuntary loss of urine due to over-distension of the bladder (RNAO, 2005).
• Functional incontinence: Urinary leakage occurring as a result to an inability to access toileting facilities due to functional and/or cognitive impairments (RNAO, 2005).
• Total incontinence: Involuntary, unpredictable, and continuous loss of urine (RNAO, 2005)

Urinary Retention
Urinary retention is incomplete bladder emptying, typically defined by abnormally high postvoid residual volumes (Doughty, 2000). There are two types of urinary retention:

• Acute Urinary Retention: Urinary retention characterized by a sudden and painful inability to void (Fitzpatrick and Kirby, 2006).
• Chronic Urinary Retention: Patients experiencing chronic urinary retention have a non-painful bladder that remains palpable and percussible after voiding (Abrams et al, 2002).

Conclusion

In this section, we discussed post-stroke urinary continence challenges and reviewed how the bladder works and types of urinary incontinence and retention.  If you have any questions or comments, please leave them below so that we can continue to work with you to provide improved urinary continence care.

Click here to advance to Module 2: Urinary Continence Assessment Recommendations.

Click here to return to the main page.

1.1 Assessing Continence History
We recommend that you assess stroke survivors’ continence history to identify transient causes and possible contributing factors to post-stroke urinary continence challenges (Steggall, 2007). Transient causes are contributors to urinary incontinence and urinary retention not related to bladder and urethral function (Skelly, 2006; Whytock, 2006). The acronym DISAPPEAR may be used as a memory prompt to assess transient causes of urinary incontinence (Whytock, 2006). Addressing transient causes may resolve the stroke survivor’s urinary continence challenges. Click here to review these transient causes.

1.2 Obtain Baseline Postvoid Residual Volume and Voiding Patterns
Conduct baseline assessments of postvoid residual volume (PVR) and voiding patterns in order to identify the presence of urinary retention and overflow incontinence. Intermittent catheterizations may be discontinued for stroke survivors who are voiding and experience 3 consecutive residuals less than 150ml (Skelly, 2006).

• If PVRs remain equal to or greater than 150ml for three consecutive voiding attempts, the stroke survivor is experiencing urinary retention (Dunn, 2007).
• Stroke survivors experiencing both high PVRs and incontinent episodes are experiencing overflow incontinence (Steggall, 2007).
• If stroke survivors are experiencing urinary retention and/or overflow incontinence, develop an appropriate management program following the Urinary Retention Practice Recommendations.

1.3 Contributing Factors to Urinary Continence Challenges
Stroke survivors may experience post-stroke ability impairments that may contribute to the development of urinary retention or urinary incontinence. Stroke survivors may be less aware of or unable to communicate the need to void. We recommend that you use information from validated tools to assess stroke survivors for the following:

• Cognitive and functional abilities
• Aphasia
• Changes in dietary patterns:
  
• Consumption of bladder irritants, such as coffee, alcohol, and artificial sweeteners:
• Use of medications following stroke that may contribute to urinary continence challenges:
  

Samples of assessment tools may be accessed by following this link to the Documents section of the website.

1.4 Discuss Knowledge, Goals, Beliefs and Attitudes Toward Urinary Continence
The relationships that you develop with stroke survivors helps you have meaningful discussions with them regarding their knowledge, goals, beliefs, and cultural attitudes toward urinary continence management. It is important to have this discussion in order to involve stroke survivors in continence care and establishing goals. The following questions may be asked in order to facilitate this discussion:

• What is your understanding of continence?
• What are your beliefs regarding continence?
• What are your continence goals?

1.5 Assess for Urinary Tract Infections
One of the primary causes of post-stroke urinary retention is the presence of urinary tract infections (UTI) (Garrett et al, 1989; Kong et al, 2000). We strongly recommend that you assess stroke survivors for the presence of UTIs. Your leadership in identifying and treating a previously undiagnosed UTI might resolve urinary retention.

1.6 Assess for Constipation
Constipation and stool impaction may impair detrusor contractility (Charach, G., Greenstein, A., Rabinovich, P., Groskopf, I., and Weintrab, M., 2001; Gray, 2000a). It is therefore recommended that you complete a constipation assessment. It is recommended that you obtain information regarding the stroke survivor’s stool frequency, character and consistency of bowel movements, and fluid intake in order in order to determine the presence of constipation among stroke survivors. Click here to obtain a sample constipation assessment tool.

1.7 Identify Environmental Barriers to Successful Toileting
Identify environmental barriers to successful toileting, including both the physical environment and attitudes of health professionals (RNAO, 2005). An assessment of toileting facilities and other potential barriers includes:

• Size of toileting facilities;
• Proximity of toileting facilities to stroke survivor;
• Accessibility of commodes;
• Satisfactory lighting;
• Availability of nurses, personal care workers, and toileting aids, such as equipment for mobility (ie: walkers) and raised toilet seats (RNAO, 2005); and,
• Advise stroke survivors to wear easily removable clothing in order to minimize the impact of reduced dexterity (Getliffe and Dolman, 2003; Brooks, 2004).

1.8 Identify Type of Incontinence
Stroke survivors may be experiencing any of several types incontinence, including transient, stress, urge, mixed, functional, overflow, or total incontinence. Identify the type of incontinence in order to proceed with developing a management strategy. You can review types of incontinence by clicking here to return to the previous post.

Conclusion
In this section we have reviewed the assessment recommendations from Clinical Practice Guidelines for the Urinary Continence Management of Stroke Survivors in Acute and Rehabilitation Settings. These recommendations will help you to better identify the continence challenges experienced by stroke survivors. We hope that these recommendations will help you work with stroke survivors to take these important first steps in improving urinary continence care. Please leave any questions or comments below.

Click here to advance to Module 3: Urinary Incontinence Management Recommendations

Click here to return to the main page.

2.2 Prompted Voiding
Prompted voiding is a behavioural intervention in which you use verbal and physical cues to assist the stroke survivor in using the toileting facilities (RNAO, 2005). We recommend it for stroke survivors with physical or cognitive impairments that are experiencing urge, stress, mixed and functional incontinence. Unlike other behavioural interventions, prompted voiding places the onus on you, the health care professional. The Registered Nurses Association of Ontario (2005) notes:

Rather than relying on an incontinence aid or clothing, the caregiver will intervene prior to the undesired bladder voiding. An individualized prompted voiding schedule is determined using a 3-day voiding record that is based on the person’s normal pattern of voiding and/or incontinence. Prompted voiding is used for the treatment of urinary incontinence in persons with physical and/or cognitive deficits, requiring timely reminders to toilet from caregivers.

The RNAO (2005) suggests that you use three primary behaviours when initiating prompted voiding:

• Monitoring: Asking stroke survivors at regular intervals if they have to toilet. You may want to monitor other signs that the stroke survivor has to toilet, such as restlessness and irritability, and take them to the toilet at regular intervals specific to their voiding patterns.
• Prompting: You prompt the stroke survivor to toilet at regular intervals and encourage bladder control between sessions.
• Praising: You encourage the stroke survivor to maintain bladder control through positive reinforcement.

The RNAO has published clinical practice guideline on prompted voiding, Promoting Continence Using Prompted Voiding, that will assist you in implementing this intervention. Communication techniques that can be used to prompt and praise stroke survivors can be found in Appendix C of the guideline.

2.3 Timed Voiding
Timed voiding is an intervention in which you assist patients with voiding at fixed time intervals. It is frequently used for patients unable to toilet independently. You focus on helping the patient to avoid incontinence episodes rather than restoring bladder function (Ostaszkiewicz et al, 2007). This is an appropriate intervention for stroke survivors with severe cognitive impairments who are unable to communicate the need to void (Ostaszkiewicz, 2007).

We recommend that you complete a 3-day voiding record in order to determine the stroke survivor’s voiding patterns. Monitor the intake and output of fluid, as well as the relationship between intake and incontinent episodes. Use this voiding record to establish a voiding schedule specific to the stroke survivor’s voiding patterns.

2.4 Use Continence Management Products
You may use continence management products to lessen the impact that urinary incontinence has on the everyday lives of stroke survivors. Discuss continence management products with stroke survivors in order to better understand both their needs and preferences. Evidence suggests that disposable insert pads are best for managing light urinary incontinence among women (Fader, Cottendem and Getliffe, 2007).

We strongly advice that you refer to these products as continence management products, rather than diapers, in order to destigmatize their use among stroke survivors. Stroke survivors may find the use of the term diapers to be derogatory.

Case studies
To better understand how these recommendations may be implemented in your setting, it may be helpful to complete case studies. To access case studies on urinary incontinence, click here.

Conclusion
We hope that the interventions that we have reviewed in this section will assist you in managing urinary incontinence among stroke survivors. Your hard work and dedication to addressing urinary incontinence helps to greatly improve the well-being of stroke survivors. If you have any questions or comments, please leave them below so that we can continue to work with you to provide improved urinary continence care.

Click here to advance to Module 4: Urinary Retention Management Recommendations.

Click here to return to the main page.

• Position male stroke survivors so that they are standing or sitting. Bed toileting positions leave men with higher PVRs (Cook et al, 1998).
• Position women in a sitting position when possible.

3.2 Intermittent Catheterization
We recommend that you use intermittent catheterization to manage urinary retention among stroke survivors. Adhere to the following protocol for intermittent catheterization when stroke survivors are medically stable (IC5, 2005):

• Monitor intake and output of fluid using a voiding record, including caffeinated beverages;
• Encourage healthy intake levels of at least 1500 to 2000ml of fluid per day; and,
• Optimize catheterization intervals by developing individualized plans according to the stroke survivor’s intake and output levels.

Follow this link to view the complete recommended intermittent catheterization protocol.

Important

While we recommend that intermittent catheterization is the preferred management option, it may be necessary to use indwelling catheters in certain circumstances. Indwelling catheters should be limited to the following: stroke survivors with intractable urinary retention; urinary retention that causes persistent overflow incontinence, infection, and/or renal dysfunction; stroke survivors with urinary retention that cannot be managed with intermittent catheterization; stroke survivors experiencing pain during catheter insertion due to enlarged prostate; stroke survivors with skin breakdown, continuous wetness, and the need for urinary monitoring; and, stroke survivors with palliative diagnoses for whom clothing changes are uncomfortable or disruptive (American Medical Directors Association, 2005; Teasel, 2007).

3.3 Use Smallest Possible Catheter Size
Stroke survivors may experience discomfort due to catheterization. Use the smallest possible catheter size in order to minimize stroke survivors’ discomfort and risk of injury (IC5, 2005).

It is recommended that catheters 10-12 F are used for women and catheters 14F are used for men (Cassel, 2006).
Conclusion
We hope that these recommendations will help you to manage urinary retention among stroke survivors. If you have any questions or comments, please leave them below so that we can continue to work with you to provide improved urinary continence care.
Click here to advance to Module 5: General Continence Care Recommendations.
Click here to return to the main page.

• Prevention of Constipation in the Older Adult Population, Registered Nurses of Ontario (2005)
• Practice Guidelines for the Management of Constipation in Adults, Rehabilitation Nurses Foundation (2002)

Healthy intake levels of fluid may decrease bladder irritation caused by a higher concentration of urine. This may cause both urinary retention and overflow incontinence. We recommend that stroke survivors consume at least 1500 to 2000ml/day and minimize the intake of bladder irritants, such as caffeine, alcohol, and artificial sweeteners.

4.2 Promote Privacy While Toileting
Promoting privacy for stroke survivors while they are toileting helps to uphold their dignity. We recommend that you do this whenever possible. This may not, however, be possible for stroke survivors at risk of falling.

4.3 Consult with the Medical Team
If urinary retention persists or the stroke survivor has complex management needs that you are unable to address, consult with the medical team to develop an appropriate individualized plan of care.

Conclusion
By completing this section, you have have reviewed all of the practice recommendations for the urinary continence care of stroke survivors. We hope that this learning package has increased your understanding of urinary continence care and started you on a journey in continence nursing. If you have any questions or comments, please leave them below so that we can continue our dialogue on urinary continence care.

Click here to advance to Module 6: Review Continence Care Recommendations.

Click here to return to the main page.

1.1 Assess the Stroke Survivors Continence History

1.2 Obtain the Stroke Survivor’s Baseline Postvoid Residual Volume and Voiding Patterns

1.3 Contributing Factors to Urinary Continence Challenges, such as Functional Abilities, Aphasia, Changes in Diet, and Consumption of Bladder Irritants

1.4 Discuss Knowledge, Goals, Beliefs and Attitudes Toward Urinary Continence with the Stroke Survivor

1.5 Assess the Stroke Survivor for the Presence of Urinary Tract Infections

1.6 Assess the Stroke Survivor for Constipation

1.7 Identify Environmental Barriers to Successful Toileting for the Stroke Survivor

1.8 Identify Type of Incontinence Experienced by the Stroke Survivor

Urinary Incontinence Management Recommendations

2.1 Assess Type and Severity of Urinary Incontinence Using a Validated Assessment Tool

2.2 Manage Urinary Incontinence Using Prompted Voiding for Stroke Survivors with Physical and Mild Cognitive Impairments

2.3 Manage Urinary Incontinence Using Timed Voiding for Stroke Survivors with Severe Cognitive Impairments

2.4 Use Urinary Continence Management Products According to the Needs and Preferences of the Stroke Survivor

Urinary Retention Management Recommendations

3.1 Ensure Optimal Patient Positioning for Voiding (Sitting for Women; Sitting or Standing for Men) According to the Stroke Survivor’s Preferences and Abilities

3.2 Use Intermittent Catheterization to Manage the Stroke Survivor’s Urinary Retention

3.3 Use the Smallest Possible Catheter Size to Minimize Discomfort (10-12F for Women; 14F for Men)

General Continence Care Recommendations

4.1 Implement a Bowel Management Protocol, if Necessary, and Promote Health Intake of Fluid

4.2 Promote Privacy While Toileting, When Possible, to Maintain the Stroke Survivor’s Dignity

4.3 Consult with the Medical Team if the Stroke Survivor has Complex Continence Care Needs that Cannot be Managed or Resolved Using the Preceding Recommendations

Conclusion

Thank you for reviewing these practice recommendations. Click here to advance to the learning assessment.

If you would like to review the learning modules, click here to return to the main page.

Upon successful completion of the knowledge test, you will receive instructions on how to retrieve a certificate of completion. Best of luck!

Click here to launch the learning assessment in a new window. After successfully completing the learning assessment, you will receive a “Certificate of Completion”.