Note from the American Medical Directors Association (AMDA) and the National Guideline Clearinghouse (NGC): The original full-text guideline provides an algorithm on "Urinary Incontinence in the Long Term Care Setting" to be used in conjunction with the written text. Refer to the "Guideline Availability" field for information on obtaining the algorithm, as well as the full text of the guideline, which provides additional details. Graded recommendations were still being finalized at the time of guideline printing and were thus not available for inclusion in this NGC summary.
Does the Patient Have a History of Urinary Incontinence (UI)?
Obtain information about the patient's past and present urinary function.
- Review the transfer summary and other chart data for indications of a UI problem.
- Review for recent or prior placement of an indwelling urinary catheter and associated diagnosis.
- Review the results of a previous UI evaluation, if any.
- If the patient has a history of UI, identify the onset and type of incontinence to the extent possible.
- Review all medication changes in the 30 to 90 days before UI is noted, to rule out medication changes as contributing factors.
See the original guideline document for Minimum Data Set (MDS) process recommendations.
Does the Patient Show Signs and Symptoms of UI?
UI is identified by direct observation (i.e., by observing an incontinence episode or finding the patient wet).
- Document any signs and symptoms of UI in the patient's medical record.
- Determine how often the patient leaks urine and how much urine is lost (small or large volume).
- Determine whether the patient uses a protective pad, brief, or other absorbent product.
Identify Factors Affecting the Patient's Urinary Continence
With the interdisciplinary team, assess for risk factors that may affect the patient's potentially modifiable causes of UI (see Table 3 in the original guideline document) so that interventions may be targeted to those factors. Consider the input of the consultant pharmacist in the review of medication effects on continence status.
Perform a Physical Examination and an Additional Work-up as Indicated
The primary purpose of the history and physical examination is to detect potentially modifiable or reversible factors that are contributing to the patient's UI. See original guideline document for details of:
- Initial examination
- Targeted physical examination
- Laboratory testing
- Other assessments, including postvoid residual testing, bladder stress testing, prostate specific antigen (PSA) testing, and urodynamic studies
Summarize Relevant Information about the Patient's UI
Identify Individual Treatment Goals and Develop a Plan of Care
The overall goal should be to improve function and quality of life and decrease episodes of UI. The most basic goals of managing UI are to try to reduce its frequency and severity and to minimize related complications. Effective treatment of underlying causes may not always be possible or pertinent because of a patient’s general condition, treatment preferences, or functional abilities. Figure 1 in the original guideline document lists categories of treatment options for specific types of UI.
Address Transient Causes of, and Modifiable Risk Factors for, UI
As appropriate, treat transient causes of UI and address modifiable risk factors—both those related to urinary tract function and those that affect urinary function by impairing an individual's overall function, mobility, level of consciousness, and so on. For example, manage delirium, treat urethritis, provide an easily accessible toilet, and offer frequent reminders to toilet and assistance with toileting if necessary.
Patients with symptoms of a UTI or of urosepsis (bacteria in the bloodstream, probably from a urinary source, with signs of sepsis) should receive appropriate treatment. The goal of treating a UTI is, at a minimum, to alleviate systemic or local symptoms. Total eradication of all bacteria may not always be feasible (e.g., in a patient who has an indwelling urinary catheter or other source of chronic bacteriuria).
Long term care (LTC) facilities should have clear policies and practices to ensure that patients are not started on antibiotics without a credible clinical rationale.
Provide a Toileting Program as Appropriate
If the patient remains incontinent after transient causes of UI have been treated, consider initiating a toileting program for appropriate patients—that is, a plan whereby staff members at scheduled times each day either take the patient to the toilet, give the patient a urinal, or remind the patient to go to the toilet.
Consider Additional or Alternate Interventions as Appropriate
Patients who remain incontinent after a toileting intervention ought to be considered for other interventions depending on the type of UI they are thought to have. Patients may have preferences concerning the type of treatment they wish to receive for UI. When appropriate, they should be asked about such preferences.
See original guideline document for details of:
- Bladder rehabilitation or bladder retraining
- Pelvic floor muscle rehabilitation
- Physiological quieting
- Electrical stimulation
Evaluate the Effectiveness of Interventions Thus Far, and Implement Additional Approaches as Indicated
If the measures described in Steps 7 through 9 are not appropriate or do not adequately resolve the patient's UI, consider other possible interventions, including pharmacologic therapy (see Table 6 in the original guideline document for a list of potential pharmacologic interventions according to type of incontinence).
Although they do not address underlying causes, incontinence devices and products may play a limited role in the management of UI or a more significant role if the underlying risks or causes of incontinence cannot be treated.
Some women whose urine retention or incontinence is associated with bladder or uterine prolapse may benefit from the placement of a pessary (an intravaginal device used to treat pelvic muscle relaxation or prolapse of pelvic organs).
Surgery for stress incontinence in women or urinary obstruction in men may be effective in some cases (e.g., transurethral prostate resection or dilation of a urethral stricture may be beneficial in selected cases).
If other interventions are not feasible or have not adequately addressed the patient's UI, consider bladder catheterization. Catheterization may be intermittent or indwelling.
Position, secure, and manage an indwelling catheter properly to minimize urethral damage and other complications (see Table 9 in the original guideline document for management guidelines). Use a sterile catheter technique for the initial insertion. Monitor for and manage complications such as pain, bleeding, urosepsis, and catheter blockage.
Monitor the Course and Consequences of UI and its Treatment
Specifically, monitor patients for:
- Effectiveness of interventions, using an objective measure of the severity of UI such as systematic recordings or a bladder diary
- Response to any medications initiated to try to control continence
- The appropriateness of changing to a less obtrusive or lower-risk intervention
- Patient satisfaction with treatment
- Side effects or complications of treatment
Monitor the Facility's Management of UI
Table 10 in the original guideline document lists sample performance measurement indicators.