Continence Best Practices: Making a Difference Biennial Conference

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1 Continence Best Practices: Making a Difference Biennial Conference Interprofessional Continence Promotion and Management in Patients with Multiple Sclerosis: Exploring Practice Complexities Barbara Grace Cowie, RN, MN, GNC(C), NCA Nurse Continence Advisor Advanced Practice Nurse UTI in LTC September 15, 2011

2 Workshop Overview Prevalence Gender differences Psycho-social impact Requirements of continence Neuro control of the bladder Neuro control of the bowel Pathophysiology bladder and bowel Treatment options Outcomes

3 Workshop Overview Barriers Overcoming barriers Continence experts Interprofessional collaboration Case studies

4 Continence Reflection Think back to an experience in your practice when you felt confident with your role in completing continence assessments and making treatment recommendations for a patient with MS who was experiencing incontinence, bladder symptoms and/or bowel management problems OR an experience when you felt a lack of confidence with your role in completing continence assessments and making treatment recommendations for a patient with MS who was experiencing incontinence, bladder symptoms and/or bowel management problems. What? So what? Now what? What have I learned about continence care from my practice experiences?

5 Person-centered Practice Person-centred Nursing Framework (McCormack & McCance 2006)

6 Revealing the Evidence Who says we need to work on improving continence care for persons with MS? Research The estimated prevalence of urogenital symptoms in MS is between 52% and 97% The severity of symptoms often correlate with the degree of spinal cord involvement = complexity Clinical Experience What is the evidence? Local Audit Patient Experience

7 Prevalence The estimated prevalence of urogenital symptoms in MS has varied, depending on the populations studied Estimates of between 52% and 97% have been cited Kalsi & Fowler 2005 The severity of symptoms often correlate with the degree of spinal cord involvement Panicker & Fowler, 2010

8 Multiple Sclerosis (MS) Multiple sclerosis (MS) is an autoimmune demyelinating disorder (Boss, 2010) There is diffuse loss of central nervous system myelin and loss of axons, but the peripheral nervous system is not involved Boss 2010 The spinal cord is often affected, and bladder symptoms are understood to occur from a disconnect between the brainstem and sacral part of the spinal cord Fowler et al., 2009

9 Gender Differences Obstructive symptoms in men: Hesitancy Slow stream Incomplete emptying Urge incontinence in women: Sudden, involuntary loss of urine Irritative symptoms of urgency, frequency, nocturia and dysuria are found equally with both sexes. Kalsi & Fowler, 2005

10 Revealing the Evidence Who says we need to work On improving continence care for persons with MS? Research The estimated prevalence of urogenital symptoms in MS is between 52% and 97% The severity of symptoms often correlate with the degree of spinal cord involvement = complexity Clinical Experience What is the evidence? Impact on quality of life for the individual and family Local Audit Low self-esteem Social isolation Depression Patient Experience

11 An important problem UI is a strong predictor of functional recovery Brittain 2001 Discharge destination - institution vs. community/home Brittain 2001; Patel et al., 2001 Impact on quality of life for the individual and family Resumption of social participation Low self-esteem Social isolation Depression Gallagher 1998

12 Neurogenic Bowel Significantly impacts quality of life Management of this problem presents many complexities There is very little research evidence to inform practice Individualized assessment Conservative interventions Coggrave 2008

13 Storage phase Emptying phase Bladder pressure Bladder filling First sensation to void Normal desire to void Bladder filling Detrusor muscle Detrusor muscle Detrusor muscle Detrusor muscle relaxes relaxed contracts relaxes Urethral Urethral Urethral Urethral sphincter sphincter sphincter relaxes sphincter tone contracts (voluntary control) tone Pelvic floor Pelvic floor Pelvic floor Pelvic floor tone contracts relaxes tone MICTURITION

14 Neuro Control of the Bladder A complex of brain networks is involved in the two processes of bladder storage and voiding The final result of these processes is either activation or inhibition of the pontine micturition center (PMC) influenced by higher centres, including the frontal lobe and hypothalamus Direct pathways from the PMC project to the sacral segments of the spinal cord (S2-S4) - Determine parasympathetic outflow to the detrusor and reciprocal activity of the motor neurons innervating the striated urethral sphincter Kalsi & Fowler, 2005

15 Neuro Control of the Bladder The bladder and urethra are innervated by three sets of peripheral nerves Pelvic parasympathetic nerves from sacral spinal cord segments S2-S4 that cause the detrusor muscle to contract Thoracic and lumbar sympathetic nerves T10-12 that control the bladder neck and urethra Pudendal nerves that stimulate the external urethral sphincter and pelvic floor muscles Woodward, 2004; Di Benedetto et al as cited by Pellatt, 2008

16 Neuro Control of the Bladder Normal bladder emptying requires: Both an intact central and peripheral nervous system to control the filling and voiding phase of micturition Bladder storage The bladder stores urine using inhibitory impulses from the PMC These inhibitory impulses pass to the sacral cord, inhibiting the activity of the parasympathetic nerves to the detrusor muscle, allowing bladder filling without a rise in detrusor pressure Woodward, 2004; Bardsley, 2000 as cited by Pellatt, 2008 Fowler, C.J., Griffiths, D. & de Groat, W.C., 2008

17 Neuro Control of the Bladder Parasympathetic nerve impulses travel from S2-S4 to the bladder via the pelvic nerve Sympathetic nerve supply (increased bladder storage), travels to the bladder and urethra via the hypogastric nerve

18 Neurogenic Bladder Lower motor neuron damage affecting the peripheral nervous system (pelvic and pudendal nerves) will result in a flaccid or hypotonic bladder Weak, underactive bladder Large residual volumes of urine Bardsley, 2000; Rigby, 2003; Zickler & Richardson, 2004 as cited by Pellatt, 2008

19 Neurogenic Bladder Upper motor neuron damage affecting the brain and spinal cord causes overactivity and spasticity Leads to uncontrolled, frequent emptying and incomplete emptying Bardsley, 2000; Rigby, 2003; Zickler & Richardson, 2004 as cited by Pellatt, 2008

20 Neurogenic Bowel Gut transit is primarily influenced by local reflexes and motility patterns set in the enteric nervous system This can be modulated by the extrinsic innervation The sympathetic thoracolumbar input is inhibitory (T9 L2), while the excitatory parasympathetic innervation derives from the vagus and sacral roots S2 S4 Emmanuel Continence Care April 16,

21 Types of Urinary Incontinence Stress Urge (OAB) Functional Overflow

22 Bladder Pathophysiology MS The most common bladder problem for persons with MS is detrusor overactivity Bladder symptoms often start with symptoms of overactive bladder (frequency, urgency and urge incontinence) Boss, 2010, Wyndaele et al., 2009 Strong urge to pass urine Large loss of urine Socially devastating This occurs in lesions above the pontine micturition centre Di Benedetto et al as cited by Pellatt, 2008

23 Bladder Pathophysiology MS Obstructive symptoms such as hesistency and urinary retention also occur Long term changes can progress to either a small spastic bladder or a large flaccid (poorly contractile) bladder (Boss, 2010) Combined storage and emptying issues Sacral spinal cord lesions can produce combined dysfunction with bladder areflexia and/or hypcontractility and sometimes various degrees of denervation of urethral sphincter and pelvic floor muscles Di Benedetto et al as cited by Pellatt, 2008

24 Bladder Pathophysiology MS Detrusor sphincter dyssynergia (DSD) Co-ordinated relaxation of the urethral sphincter and contraction of the detrusor muscle Controlled by the PMC With DSD the bladder and sphincter contract simultaneously DSD is caused by lesions below the PMC but above the sacral micturition centre DSD may result in bladder emptying problems Fowler, 2009; Wyndaele, 2009; Pellatt, 2008

25 Bowel Pathophysiology MS The level and completeness of injury are key factors in determining colorectal function and the nature and extent of subsequent symptoms In multiple sclerosis there are often multiple lesions changing overtime, making this extremely difficult to define Emmanuel Continence Care April 16,

26 D I S A P P E A R DISAPPEAR Transient Causes of UI Delirium Intake of fluid Stool impaction Atrophic changes/urethritis Psychological problems Pharmaceuticals that can contribute to incontinence Excess urine output Abnormal lab values Restricted mobility Whytock, S (Chapter 3) Promoting Continence Care, A Bladder and Bowel Handbook for Care Providers. Skelly J, Carr M, Cassel B, Robbs L, Whytock S, Edited by Paula Eyles 2006

27 Age Related Changes Increased Detrusor Overactivity Nocturnal urine output BPH PVR (<100 ml) Bacteruria (20%) Decreased Bladder Contractility Bladder Sensation Sphincter Strength (F) Unchanged Bladder Capacity Bladder Compliance

28 Impact of cognition Cognitive decline with progressive MS Ability to follow and understand prompts or cues Ability to interact with others Ability to complete self care tasks Social awareness

29 Structured Assessment Specialist professional structured assessment: Functional Ability - The degree of physical disability (e.g. loss of mobility) may make urinary symptoms more pronounced - Fatigue is a factor The assessment may take 2 to 3 visits

30 Treatment Options Surgery Medication Behavioural Most cases of UI can be effectively managed with conservative approaches.

31 Conservative Treatment Options Functional Toileting ISC Stress Overflow Urge Pessaries Behavior modification Kegal Exercises Urge Suppression

32 Bladder retraining Bladder retraining with urge suppression involves three components Educating patients about the mechanisms underlying incontinence and continence A scheduled voiding regimen with gradually progressive voiding intervals and a gradual increase in voided volumes Techniques to suppress unstable bladder contractions (urge suppession) - An urgency control strategy using distraction and relaxation techniques - Pelvic floor muscle exercises Burgio et al 1998; Wilson et al 2002

33 Teaching Urge Suppression For urgency and frequency to prevent dribbling on your way to the toilet Stop, sit down and do 5 quick Kegel exercises (1 second each) Relax your abdominal muscles by taking 3 to 4 deep cleansing breaths. Slowly inhale and exhale Be positive. Think: I can hold and wait Get up slowly and walk to the bathroom

34 Intermittent Catheterization Intermittent catheterization is a preferred intervention to manage chronic retention and overflow incontinence This method allows the bladder to be emptied at regular intervals thereby preserving bladder tone IC helps the profusion of the bladder lining and reduces the risk of infection Cassel & Carr, 2007 Cottenden et al., 2008 Getliffe et al., 2007

35 Intermittent Catheterization IC allows some patients to void before using the catheter allowing patients to have more control over emptying their bladders regularly and completely Patients may be taught to do self-intermittent catheterizations or they can be done by a care provider Resource: Intermittent Self-Catheterization A Step by Step Guide for Men and Women h%20book.pdf

36 Anticholinergic Medication Anticholinergic medications suppress involuntary bladder contractions and increase bladder capacity Favazza, 2005 as cited by Pellatt & Geddis, 2008 These medications are often used in conjunction with ISC as a stable bladder is required to store urine without leakage or detrusor contractions Bennett, 2002 as cited by Pellatt & Geddis, 2008

37 Anticholinergic Medication Side-effects include urinary retention, constipation and dry mouth Examples, oxybutynin (Ditropan) and tolteridone (Detrol) Tolteridone does not cross the blood-brain barrier It is a safer medication to use in patients with cognitive impairment Fowler & O Malley, 2003 as cited by Pellatt & Geddis, 2008

38 Suprapubic catheters Insertion of a catheter directly into the bladder via an abdominal wall incision called a cystotomy Bardsley, 2005 as cited by Pellatt & Geddis, 2008 An alternative option to ISC for patients who are unable to carry out ISC, have ureteric reflux, are wheelchair users and who are sexually active Peate, 1997, as cited by Pellatt & Geddis, 2008 Suprapubic catheter practice guidelines Harrison, S. et al. 2010

39 Neurogenic Bowel The goal is to achieve control over neurogenic bowel dysfunction To achieve a predictable evacuation of the bowel at a chosen time & frequency Promoting bowel continence and prevention of constipation Coggrave 2008

40 Neurogenic bowel Consistent toileting following a triggering meal Fluid and fibre Stool consistency Laxatives Stimulant suppository Coggrave 2008 There is a need for research on all aspects of managing bowel dysfunction in MS to improve patients quality of life Norton & Chelvanayagam, 2010

41 Continence Outcomes Aid to clinicians in selecting an outcome measure for the assessment of UI (Tannenbaum & Corcos 2008) Consideration of both scientific rigour & clinical utility Most rigorous validation: Incontinence Impact Questionnaire King s Health Questionnaire Incontinence Quality of Life Questionnaire Urogenital Distress Inventory Most practical for clinics: Bladder diaries Goal-attainment scales International Consultation on Incontinence Questionnaire (Tannenbaum & Corcos 2008)

42 Revealing the Evidence Who says we need to work On improving continence care for persons with MS? Research The estimated prevalence of urogenital symptoms in MS is between 52% and 97% The severity of symptoms often correlate with the degree of spinal cord involvement = complexity Lack of a in-depth structured assessment Myths and attitudes Lack of knowledge & resources Lack of access to skilled continence experts Clinical Experience What is the evidence? Impact on quality of life for the individual and family Local Audit Low self-esteem Social isolation Depression Patient Experience

43 Barriers to Continence Care Lack of knowledge Professionally - Beliefs/myths about UI - Attitudes - Knowledge related to assessment & treatment Institutional/external factors - Workload demands - Environmental support - Co-worker support - Underreporting to health care professionals General Public - Beliefs/myths about UI - Attitudes - Knowledge related to assessment & treatment Lack of funding For services Lack of access to skilled continence practitioners

44 Revealing the Evidence Who says we need to work On improving continence care for persons with MS? Research The estimated prevalence of urogenital symptoms in MS is between 52% and 97% The severity of symptoms often correlate with the degree of spinal cord involvement = complexity Lack of a in-depth structured assessment Myths and attitudes Lack of knowledge & resources Lack of access to skilled continence experts Clinical Experience What is the evidence? Local Audit Self-assessment What would ideal continence care look like? What structures and processes do we have in place? How do we bridge the gap? Impact on quality of life for the individual and family Low self-esteem Social isolation Depression Patient Experience

45 Access to Continence Care There were wide variations in knowledge, attitudes and practice. In a survey of Canadian Family Physicians 46% indicated they understood UI 38% had an organized plan 35% were comfortable asking about UI Swanson et al., 2002, 48, 86-92

46 Overcoming Barriers Urinary symptoms in people with MS are often poorly assessed and/or underreported Wyndaele, publication by Cheater: There is a growing body of evidence that UI is treatable or symptoms can be significantly improved That are significant shortfalls in the quality of continence care highlighted consistently in the international literature Need to address not only from an individual practitioner perspective but also at the levels of the interprofessional team and organization

47 Continence Experts Continence nurses and physiotherapists are able to provide specialty management for incontinence using conservative, behavioural interventions Other interprofessional team members have a valuable role Social Work (psycho-social impact, finances) Clinical Pharmacist (pharmacological interventions) Occupational Therapist (environmental factors, transfers, sitting balance)

48 Continence Experts Specialists can provide secondary management Urologists Urogynecologists Gynecologists (Awesome) Geriatricians Examples include: medication Botulinuum toxin external sphincterotomy urethral stent bladder augmentation, urinary diversion sacral nerve stimulation Pellatt & Geddis, 2008

49 Interprofessional Collaboration Sharing a common language Value the different contributions that are made by other team members Shared planning, decision making and responsibility Corner (2003) observed that multi professional healthcare teams develop over time, becoming more collaborative and consensual with individual members of the team becoming less dominant

50 Interprofessional Collaboration Suddick & De Souza (2006) report a qualitative study on therapists experiences and perceptions of teamwork in neurological rehabilitation The authors explore reasoning behind the team approach, structure and composition of the team and teamworking processes

51 Interprofessional Collaboration Doumoulin, Korner-Bitensky & Tannenbaum (2007) conclude that their findings suggest: Strategies are needed to encourage clinicians to increase their focus on UI assessment and management Introduction of a structured assessment model as a good starting point Easy clinician access to the emerging evidence

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