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Continence Strategies:
Towards Independence in the Elderly
Karina So
Clinical Nurse Consultant
Urology / Continence Management
Concord Hospital
Practical strategies
• Curative therapy for mild SI
• Symptom management for SI & UI
• Containment for severe and permanent
Urinary incontinence
• Nocturnal incontinence
• Risk management on IDC/SPC/CISC
Urge incontinence is associated with a
modest increase in falls.
Chiarelli et. Al.(2008) Urinary incontinence is associated with an increase in falls: a systematic review” Australia Journal
of Physiotherapy 55: 89-95
Common Continence Problems
in the elderly population
• Stress incontinence
(SI)
• Urge incontinence (UI)
• Mixed incontinence
• Overflow incontinence
• Functional incontinence
Drugs that can cause urinary incontinence
Agent
Mechanism of Action
Antihypertensive
Type of Incontinence
Stress Incontinence
Sphincter relaxation
Prazosin, Labetolol
Bladder relaxant
Anticholinergics
Tricyclic Antidepressants
Promote incomplete
emptying
Bladder Stimulant
Enhance detrusor
instability
Caffeine, Cholinergics
Sedative
Overflow
Incontinence
Urge Incontinence
Urge incontinence
Antihistamines,antidepressants Reduce awareness of
antipsychotics,Tranquilisers,
bladder sensation
Hypnotics
Miscellaneous
Alcohol
loop diuretics
Lithium
Lower inhibition
Increase bladder filling,
Polydipsia
Urge incontinence
Stress Incontinence (SI)
• Mild SI - Curative therapy
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Pelvic Floor Muscle Exercises
Behavioural modification
Review medication(s)
Healthy diet & maintain healthy wt.
Regulate fluid intake & healthy bowel habit
Real-time Ultrasound Scan
• Patient can watch pelvic floor muscles
contract and relax as you retrain them
(visual feedback on performance).
• It is a tool to encourage compliance.
• It does not measure PFM strength.
Moderate SI
Symptom management
– Mild SI care path
– Intravaginal device – pessary ring,
tampon, Contiform device.
– Selection of continence products
uridome
Symptom management SI
• Contiform!
• Penile clamp should be
released every one to two
hours to empty the
bladder and prevent
damage.
Severe and permanent SI
Supportive care/ Risk Management
– Containment
– Social continence
– Prevent skin problems, UTIs, odour control
– Government Continence Aids schemes
• PADP
• CAAS/CAPS
• DVA – gold card
Management of Urge Incontinence
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Regulate fluid intake:amount,type, time.
Bladder training strategies +/- medication
Clothing- reduce layers, zipper/belt
Medications – dose, time, route.
Healthy diet, healthy bowel.
Selection of appropriate continence aids
Assess eligibility for Government
schemes:
PADP / CAAS/ DVA
Bladder Training therapy
For mild-moderate sensory and motor
urgency.
• Deferment strategies (take control)
– Pelvic floor muscle contractions
– Talk to your bladder
– Tactile sensation/pressure
– Distraction (think hard)
• Identify Optimal voiding time
• Frequency, volume & urgency diary
Drugs used to treat OAB
Anticholinergics/Antimuscurinic
• Propantheline (Pro-banthine 15 - 30mg q.i.d.)
• Oxybutynin (Ditropan 5mg up to q.i.d.)
– Oxytrol transdermal patch (3.9mg twice a week)
• Tolterodine (Detrusitol 1 - 2mg b.i.d.)
• Darifenacin (Enablex)
• Solifenacin (Vesicare 5 – 10mg daily)
Travel or bed time companion
Nocturnal incontinence
Booster pad
Pull up pants
Stricture therapy – patient specific
• Identify the optimal time for urethral
dilatation before a reduction in urine flow.
• Select the size and type of firm catheter.
• Educate and support patient to perform
regular self dilatation.
Coude tip firm nelaton catheter
Management of
Acute Urinary Retention
• Decompress the
bladder using 100%
silicone catheter size
14/16
• Select the most
appropriate drainage
device – bag / valve
• Educate patient &
carer on IDC care
Catheter size
12 FG
14 FG
16 FG
18 FG
20 FG
22 FG
24 FG
Colour code
Balloon Size
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3 ml
5 ml
10 ml
20 ml
30 ml
60 ml
Catheter valve & leg bag
Management of
Chronic Urinary Retention
• Prevent recurrent symptomatic UTI
• Identify high risk cases for urosepsis and
prepare care plan
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Use antibacterial soap for daily hygiene
If possible, high fluid intake > 2 litre/day
Prevent and correct constipation
Avoid trauma during catheter replacement procedure
Use catheter fixation device to avoid traction
Frequency of IDC or SPC replacement is
individualised.
– Periodic Urology review
Neurogenic bladder
CISC +/Anticholinergic
Medication
Queen Square Bladder
Stimulator $75
Management of CISC
• Reduce Symptomatic UTI –
assess CISC technique,
frequency of CISC, equipment care,
single use versus reusable catheter.
• Educate patient on monitoring of residual
volume – bladder diary.
• Periodic urology review.
Class of laxatives/time to effect
Bulk forming agents
Oral, 48-72 hrs.
Osmotic agents
Oral, 24-72 hrs.
(sorbitol, lactulose,glyerol)
Osmotic agents
Oral, 0.5 – 3 hrs.
(Macrogol or saline laxatives)
Stool softeners
Oral, 24 -72 hrs.
Stimulant
Oral, 6- 12 hrs.
Government Continence Aids
Schemes
• NSW Health – Enable Health
– PADP
• Federal Government Schemes
– CAAS
– CAPS from July 2010
– DVA for veterans with gold card
PADP Transition to
Enable Health
• Website:
www.health.nsw.gov.au/health-publicaffairs/factsheets
• One centralised body
• Office is based in Parramatta
• Transfer of PADP data in stages
Continence Aids Assistance
Scheme (CAAS)
• CAAS is an Australian Government scheme offering assistance to
eligible people who have permanent and severe incontinence.
• The scheme covers children aged 5 to 15 years, and adults over
64 years with permanent incontinence due to neurological
conditions (Cat.A).
• The scheme also includes all causes of permanent
incontinence, not just neurological causes, for those people who
hold a pensioner concession card and their dependents (Cat.B).
• Website: www.intouchdirect.com.au
• The National Continence Helpline 1800 330 066
Continence Aids Payment
Scheme (CAPS)
As of July 2010 …..
• Clients can receive a one off payment of up
to $489.95 to purchase their own products.
• Can nominate the payment goes to an
agency/ supplier.
• CAPS payment is exempted as income.
• Contact Medicare Australia Office for
information 132 011
Role of
Medicare Australia
As of July 2010..
• Respond to enquires about CAPS.
• Receive and process CAPS applications.
• Make payments directly into a CAPS client’s
nominated bank account or nominated
provider’s account.
• Send statements regarding the payment to
clients.
• Supply CAPS Application form