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NR578 Standardized Procedure Worksheet Name: Carefully read the assignment guidelines and rubric and complete each section of the worksheet below.
1. Definition a. Disease or condition Urinary incontinence in older adults b. Pathophysiology Urinary incontinence as described by Leslie et al. (2024) is the leakage of urine, which is a common condition, within the older adult population, usually individuals within nursing homes, yet can also affect younger adults as well. Urinary incontinence is also known as overactive bladder, usually seen in older women, then men. During urination, the muscles within the bladder tighten to move urine to the urethra, yet the muscles around the urethra tend to relax and let urine pass from the body. This is caused by the muscles in or around the bladder not working properly, causing leakage, which results in urine incontinence as described by the National Institute of Aging (2022). As mentioned by Leslie et al. (2024) there are 5 main types of incontinence such as stress incontinence which is caused by sneezing, coughing, or exertion that is caused by pelvic floor weakness, sphincter weakness or urethral hypermobility. Urge incontinence is described as the urge to urinate, due to the overactivity of the detrusor muscle. Conditions that affect urge incomitance can include OAB, Parkinson’s, and MS. Mixed
incontinence involves leakage of urine due stress and urge incontinence. Overflow incontinence involves an impaired detrusor contractility and bladder outlet obstruction. Many different conditions can cause muscle instability this from diabetes, spinal cord injuries, and MS. Whereas the obstruction may be due to pelvic masses, organ prolapses, or urethral strictures. Functional incontinence is due to environmental or physical barriers when using the bathroom. c. Incidence and prevalence According to the NIH (2024) annual data report, as of 2024 the incidence rate of urinary incontinence for older adults was around 43% of individuals not in nursing homes, where 70% experienced urinary incontinence who were in a nursing home. From 2015-2021 the annual incidence was 290 out of 10,000 individuals affecting ages 65 and older. As mentioned by the NIH (2024) on average over 650,000 people ages 65 and older were seen having some sort of symptoms of urinary incontinence where over 212,000 were men, and over 430,000 women. When looking at the prevalence the NIH (2024) mentions that the chance of having urinary incontinence increases with age, where 60% of females are likely to experience UI compared to 35% of males. Also mentioned by Leslie et al. (2024) older women over the age of 60, 9 to 39% report some form of incontinence daily. Where in men it ranges from 11-34%, where 2-11% have incontinence daily. But that also depends on the type of incontinence. For instance, as described by Leslie et al. (2024) when looking at stress incontinence the prevalence is 24- percent in women older then 30. Urge incontinence is 9% of women ages 40 to 44, where 31%
As a Nurse Practitioner, I intend to practice in the state of Michigan. If I have a patient who presents with symptoms of urinary incontinence, I will perform my exam and obtain a full history and from there provide them with the best recommendations. If the patient still experiences frequent episodes of urine leakage, pain or blood that is when I would consult them to see a Urologist, where they are more specialized in that field and can perform different testing and offer recommendations based on their conclusions.
3. Diagnostic tests a. Testing As mentioned previously, you can do a pelvic exam on a female, or do a prostate exam on a male, which can look for any abnormal findings. You may also obtain a urinalysis to see if there is any of infection or blood. You can have the patient keep track of a bladder diary which obtains information on the amount of fluid they intake, urinary frequency, urgency, and any accidents they may have. Another thing you can do is obtain a PVR, cough and pad test. As a provider you can also order imaging such as an ultrasound or CT scan. b. Expected results As mentioned by Leslie et al. (2024) some of the expected test results include the following. When looking at a urinalysis you will notice abnormalities such as blood, glucose, or bacteria that can lead to UTI’s. Bladder diary will consist of having the urge to urinate suddenly, involuntary leakage, drabbing, and increase in frequency of having to urinate. PVR showing more then 50 CCs of urine after you just went. when having the patient cough, urine will leak
which indicated stress incontinence. Also just by your physical examination, you will notice some weakened pelvic floor muscles, and evidence of a prolapse.
4. Management a. First-line medications As mentioned by Nandy & Ranganathan (2022) first line medications used to treat urinary incontinence includes Anticholinergics which help relax the muscles within the bladder which helps reduce the urgency and frequency when having to urinate, usually used with OAB. Medications within this class of medications include Oxybutynin (Ditropan XL). Oxybutynin as described by Dwyer et al. (2023) is indicated for patients with OAB or symptoms of detrusor overactivity, which involves urinary frequency and urgency. Typically, the starting dose of Oxybutynin is 5 mg’s twice or three times a day depending on each person and should not exceed more than four times a day for adults. Also mentioned by Dwyer et al. (2023) Oxybutynin is contraindicated in patients with urinary retention, bladder obstruction, or poorly controlled narrow angle glaucoma. When looking at drug interactions, Oxybutynin should be used in caution when using potent CYP3A4 inhibitors, that include Ketoconazole, Miconazole, or Clindamycin as described by Dwyer et al. (2023). Another medication used to help treat urinary incontinence is Tolterodine (Detrol LA). As mentioned by Narain & Parmar (2023) Tolterodine is a gold standard medication for OAB, and the 3rd^ most favored antimuscarinic. The initial starting dose is 2 mg’s extended release twice a day, or you can take 4 mg’s once a day. Contraindications for Tolterodine as mentioned by Narain & Parmar (2023) include patients who
symptoms. Imipramine comes in both tablets that consist of 10, 25, and 50 mgs, and capsules that come in 75, 100, 125, and 150 mgs as described by Fayez & Gupta (2023). The starting dose of this medication should begin at 10 mg’s once a day. If you feel like the medication is not working, the provider may increase as needed. Contraindications for Imipramine as described by Fayez & Gupta (2023) include having a previous hypersensitivity reaction to the medication and used concurrently with MAOIs. This medication should not be used in conjunction with Buspar, Fentanyl, Lithium and Tryptophan, which can lead to serotonin syndrome as described by Fayez & Gupta (2023). Another medication that you can use as mentioned by Gandi & Sacco (2021) Duloxetine (Cymbalta), which is typically given for stress incontinence, but it helps by increasing the sphincter tone and improving continence symptoms. The starting dose is 20 mg’s taken twice a day, can be increased to 40 mg’s if needed as described by Dhaliwal et al. (2023). Cymbalta is contraindicated in patients who are taking an MAOI, or uncontrolled closed angle glaucoma. It should also be avoided in individuals who have liver failure and renal impairment. It should also be treated with caution in patients who are pregnant, breastfeeding, and elderly. Also mentioned by Dhaliwal et al. (2023) Duloxetine should be avoided if patients are taking Abciximab, Alfentanil, Amoxapine, Aspirin, and many more. Speak with your provider before starting the medication. c. other treatment
Other non-pharmacological treatments for urinary incontinence for older adults as mentioned by the National Institute of Aging (2022) includes lifestyle changes such as weight management, avoid smoking, bladder training, such as using a toilet schedule to help retrain the bladder. Other treatment options include Pelvic floor exercises such as Kegel exercises and biofeedback. You may also use medical devices such as Pessaries, catheters, and sacral nerve stimulation if need be. Providers will always want to start with the least invasive strategies first before starting someone on medications. d. Client education When dealing with urinary incontinence it is important to follow directions as noted by your provider. This can include taking medication as prescribe, or modifying lifestyle changes such as exercising, eating healthy, avoiding smoking, and doing pelvic exercises. Contact your provider if you exercise adverse effects from the medication such as new onset confusion, agitation, Hallucinations, palpation, or nausea and vomiting as these may be severe reactions in which you need to stop your medication. If you feel shortness of breath, chest pain, difficulty breathing you need to go to the emergency room for evaluation. e. Follow-up when starting a patient on medications for urinary incontinence you should follow up with them in about 1 to 2 weeks so you can see how they are doing on it, or if they are experiencing any side effects to the medication in which changes need to be made. After this you
References Dawood, O., & El-Zawahry, A. (2023, August 28). Mirabegron. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK538513/ Dwyer, J., Tafuri, S. M., & LaGrange, C. A. (2023, August 17). Oxybutynin. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK499985/ Gandi, C., & Sacco, E. (2021, November 15). Pharmacological management of urinary incontinence: Current and emerging treatment. Clinical pharmacology: advances and applications. https://pubmed.ncbi.nlm.nih.gov/34858068/ Leslie, S. W., Tran, L. N., & Puckett, Y. (2024, August 11). Urinary incontinence. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK559095/ Nandy, S., & Ranganathan, S. (2022, September 19). Urge incontinence. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK563172/ Narain, S., & Parmar, M. (2023, May 23). Tolterodine. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK557858/ Urinary incontinence in older adults | National Institute on Aging. Urinary Incontinence in Older Adults. (2022, January 24). https://www.nia.nih.gov/health/bladder-health-and- incontinence/urinary-incontinence-older-adults
U.S. Department of Health and Human Services. (2021). Symptoms & causes of bladder control problems (urinary incontinence) - niddk. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/urologic-diseases/bladder- control-problems/symptoms-causes
