A nurse is admitting a client who is about to undergo surgery for benign prostatic hypertrophy

Incontinence is rarely the reason a patient is admitted to hospital; however, it plays an important part in their recovery. Continence issues are often treatable and, in some cases, reversible.

Hospital admission presents an excellent opportunity to investigate continence issues and develop a management plan. This could improve the patient’s experience and recovery, and have lasting positive impact after discharge.

In addition to following health service policy and procedures, the following actions can help identify patients with continence issues and risks.

Screening questions

Continence is a sensitive issue. Even though we might talk about this topic with patients every day, we need to be mindful to:

• actively listen to the patient and avoid making judgements
• respect the patient’s right to choose the most appropriate treatment option.

While there are no validated screening tools available, when a person is admitted it is useful to establish their usual bowel and bladder habits. Ask these screening questions:

• Do you leak urine before you get to the toilet?
• Do you have to wear pads?
• Do you suffer from constipation or diarrhoea?
• Do your bowels or bladder ever cause you embarrassment, pain or concern?
• Are you rushing to the toilet or looking for the toilet all the time?
• Are you going to the toilet every half an hour? (in addition to leaking urine, overflow incontinence can also be identified by frequency)
• Was this an issue before you were ill or has it become worse?

If a patient answers YES to any of these questions, they should be assessed for incontinence.

If the person has a pre-existing cognitive impairment or is experiencing delirum, confirm their answers with their family or carer. If applicable, contact the patient’s residential care facility to obtain their continence plan. This information will help identify the risk of episodes of incontinence during their stay.

Assess contributing factors

As a first step, we should seek to eliminate as many contributing factors to incontinence as possible.

Use DIAPPERS to screen for reversible causes1:

• D elirium
• I nfection--urinary (symptomatic)
• A trophic urethritis and vaginitis
• P harmaceuticals
• P sychological disorders, especially depression
• E xcessive urine output (for example, from heart failure or hyperglycemia)
• R estricted mobility
• S tool impaction

Also ask about:

• decreased fluid intake
• urinary retention
• lack of toilet access
• whether the patient is emptying their bladder, especially if they have a neurological condition.

Use the Urinary Distress Inventory to check for symptoms of incontinence on admission.

Once you have identified an issue and treated underlying causes, further assessment may include physical examination, taking a brief targeted history, gathering more information on the person’s usual baseline functional abilities and using standardised tools to gather more evidence.

Take a history

A person may have a mixture of continence types, which can make the underlying cause more difficult to work out. Take a brief and targeted history, gathering the following information.

Bladder and bowel symptoms

• urge
• stress
• voiding difficulty - hesitancy, intermittency, weak stream, incomplete emptying
• blood in the urine (haematuria)
• waking at night to go to the toilet (nocturia)
• pain or difficulty urinating (dysuria)
• postmenopausal/prostatism

Exclude

• malaena
• rectal bleeding
• anaemia
• loss of weight
• unexplained change in bowel habits
• nocturnal diarrhoea
• abdominal or pelvic mass.

When the problem occurs

• >during the day or during the night

Women

• gynaecological/obstetric history (the most common cause of stress urinary incontinence in women is childbirth).

Men

• urologic history (the most common cause of stress urinary incontinence in men is benign prostatic hypertrophy).

Other medical conditions or chronic diseases

• arthritis and related disorders
• musculoskeletal conditions
• neurological conditions such as Parkinson’s Disease, Multiple Sclerosis
• stroke
• diabetes
• dementia.

Medications

• diuretics
• high blood pressure medications
• antidepressants and sedatives
• muscle relaxants and sleeping pills
• calcium channel blockers (can cause constipation)
• non-prescribed drugs.

Fluid and fibre intake

How they are managing

• mobility
• using toilet facilities
• continence aids
• the social and routine activities. Some people report a restriction on their ability to lead their lives2 and stigma about incontinence can be a barrier to seeking help.3

Examine relevant systems

If needed, check the following:

• Fluid status and signs of dehydration
• Abdominal examination and rectal and genital examination, looking for
  • palpable bladder
  • incontinence associated dermatitis
  • for women
    • signs of vaginal atrophy or prolapse
    • pelvic floor muscle contraction
  • for men
    • prostate shape, size and consistency
    • pelvic floor muscle strength.
• Cardiac and respiratory examinations:
  • cardiac failure history and treatment
  • obstructive sleep apnoea (can lead to nocturnal polyuria and nocturia)
• Neurological examination to include cognition and function/mobility.

Investigate the evidence

The following investigations can help us better understand urinary tract function, other conditions, patient management and the degree of continence to aim for (dependant, social, independent).

• Two-day bladder chart:
  • include voided volumes for two consecutive days and nights
  • note if incontinent and the degree of leakage (damp/wet/soaked).
• Urine full ward test (dipstick): refer the patient to medical staff if nitrite/leucocyte/blood positive.
• Bowel chart: Bristol Stool Chart©.
• Post-void residual scale: is collected using a bladder scanner
  • if < 100 mL - no action
  • if > 100 mL - refer to medical staff. Incomplete bladder emptying leads to urinary stasis and increases risk of UTI
  • if >500 mL – refer to medical staff as soon as practicable. This may imply urinary retention requiring catheterisation.
  • Note: When using the scanner select male or female setting; for female with hysterectomy, select male setting.
• Abdominal X-ray
  • May be recommended to rule out abdominal masses and can be useful in identifying faecal impaction.

1. Resnick, N.M. and S.V. Yalla, Management of Urinary Incontinence in the Elderly. The New England Journal of Medicine, 1985. 313: p. 800-804.

2. Mitteness, L.S. and J.C. Barker, Stigmatizing a normal condition: urinary incontinence in late life. Medical Anthropology Wuarterly, 1995. 9: p. 188-210.

3. Heintz, P.A., C.M. DeMucha, M.M. Deguzman, R. Softa, Stigmas and microagression experienced by older women with urinary incontinence: A literature review. Urologic Nursing, 2013. 33: p. 299305.

Takeaways:

• Benign prostatic hypertrophy, if left untreated, may lead to chronic urinary retention.
• Medical therapy failure may warrant urologic outflow studies and lead to surgery, such as transurethral resection of the prostate (TURP), to reduce bladder outflow obstruction.
• TURP complications include bladder spasm, urinary incontinence, hemorrhage, and infection.

History and assessment

After receiving report from the post-anesthesia care unit (PACU) nurse that Mr. Denby’s surgery and PACU stay were uneventful, you assess his orientation and pain level. Mr. Denby’s vital signs are BP 130/84 mmHg, HR 100 beats per minute (bpm), respiratory rate RR 18 breaths per minute, and SpO2 98% on room air; he’s afebrile.

You note that Mr. Denby’s HR is up from the 80s in the PACU. You assess his level of consciousness and document a Glasgow Coma Scale (GCS) of 15/15. At 2:00 pm, you assess his pain level as comfortable (5/10).

On the scene

At 4:00 pm you enter Mr. Denby’s room to obtain vital signs and move him to a chair for dinner. His vital signs are BP 110/78 mmHg, HR 124 bpm, RR 20 breaths per minute, and SpO2 94% on room air. He’s afebrile, and his pain level is 5/10 due to bladder spasms. In addition to the decreased BP and rising HR, you note increased red coloration and a number of dark colored clots in the CBI drainage.

You report your findings to Dr. Jones, Mr. Denby’s urologist. When you re-enter the room, you note Mr. Denby’s color is paler than on transfer to the unit and retake his vital signs: BP 100/76 mmHg, HR 140 bpm, RR 20 breaths per minute, and SpO2 92%. You apply a nasal cannula at 3 L/min and prepare catheter irrigation equipment for Dr. Jones.

Outcome

As Dr. Jones manually irrigates the catheter, removing several clots, Mr. Denby becomes less responsive (GCS 13/15). You call the rapid response team (RRT). The team places Mr. Denby on a cardiac monitor, which shows sinus tachycardia at 142 bpm. Two minutes later, the monitor shows ventricular tachycardia, and he becomes unresponsive, with no pulses. The RRT performs cardiopulmonary resuscitation (CPR) and administers I.V. epinephrine 1 mg, followed by 1 shock and 5 CPR cycles. Mr. Denby converts to sinus rhythm and is transferred to the ICU.

During Mr. Denby’s hospital stay, hand-off reports include vital signs, GCS, and CBI changes. The family receives regular updates.

Education and follow-up

If left untreated, BPH may lead to chronic urinary retention. Initially, medical therapy may be used to treat symptoms. Medical therapy failure may warrant urological outflow studies and lead to surgery, such as TURP, to reduce bladder outflow obstruction. TURP complications include bladder spasm, urinary incontinence, infection, and bleeding.

Patient education should include complications, physical activity limitations, pain control options, and follow-up appointments with the surgeon.

TURP may be perceived as “routine,” but any procedure has complications, as Mr. Denby’s case illustrates. Your quick identification of bleeding and changes in his vital signs and level of consciousness enabled prompt treatment and a positive outcome.

*Names are fictitious.

Norine D. Pulliam is an associate professor in the department of nursing in the College of Health Sciences at West Chester University in West Chester, Pennsylvania.

References

Society of Urologic Nurses and Associates. Benign prostatic hypertrophy: Patient fact sheet. 2019.

Harding MM, Kwong J, Roberts D, Hagler D, Reinisch C. Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume. 11th ed. Saint Louis, MO: Mosby; 2019.

Key words: Benign prostatic hypertrophy, Continuous bladder irrigation, Transurethral resection of the prostate