Module 2: Continence Assessment
You are on the frontlines in assessing stroke survivors for urinary incontinence and retention. This is a necessary first step in managing and/or resolving these challenges. In this section, we provide an overview of the assessment recommendations that appear in Clinical Practice Guidelines for the Urinary Continence Management of Stroke Survivors in Acute and Rehabilitation Settings.
These include assessing the following: a) continence history; b) postvoid residual volume and voiding patterns; c) contributing factors; d) knowledge beliefs and goals for urinary continence; e) presence of urinary tract infections; f) constipation; g) environmental barriers to successful toileting; and, h) identifying type and developing a management plan.
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:
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.
