Module 3: Urinary Incontinence

Nurses like you play an important role in managing urinary incontinence among stroke survivors. As discussed elsewhere on this website, stroke survivors experience a high prevalence of urinary incontinence, which has an adverse affect on stroke survival, disability, and institutionalization rates. In this section, we review the interventions that you may use to manage urinary incontinence. These include the following: a) assessing type and severity; b) prompted voiding; c) timed voiding; and, d) using continence management products.

2.1 Assessing Type and Severity
We recommend that you complete a full assessment of urinary incontinence using a validated assessment tool in order to identify the type and severity of urinary incontinence experienced by the stroke survivor. The IC5 Continence Care study’s urinary incontinence assessment tool is one such tool. You can review a copy by following this link.

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.

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