Managing Urinary Incontinence after Stroke

After a stroke, tell your health care provider if you have leaking urine and practice good personal hygiene by wearing clean, dry clothing and cleaning daily your perineal area.

Following a stroke your bladder might not function as smoothly as it did before the stroke. Incontinence (in-con-tin-ents) is the loss of voluntary control over urination or “wetting your pants”. Incontinence is a treatable medical condition.

Functions of your Bladder

The bladder has two functions: to store urine and to pass urine.

What are medical reasons for Urinary Incontinence?

Chronic illnesses such as stroke can slow your physical function, like walking, and ease of getting to the toilet.
You may have a bladder infection. Check to see if you have a fever, cloudy urine, bad smelling urine, burning with urination, feeling confused or disoriented.
Urethritis (inflammation of the tube that connects the bladder to the outside of the body) in men or women and vaginitis (inflammation of the female sex organ) in women can cause loss of bladder control.
An enlarged prostrate gland (tissue that fits around the tube which connects the bladder to the outside of the body) in men can cause the bladder to not empty all the way.
You may not be drinking enough fluids. Low fluid intake could affect the signals to urinate.
Medications such as tranquilizers, sedatives, hypnotics, and antidepressants may cause changes in bladder muscle function and decrease your sensitivity to body signals.
Use of diuretics, “water pill”, should be timed around activities where you plan to leave home. Taking the pill in the morning and not at bedtime will help avoid incontinence.

What Causes Incontinence?

There are several factors that can contribute to this problem.

Some stroke survivors are not able to make it to the bathroom in time before the urine comes out because of difficulty moving.
The nerves that control sensations for urinating are linked to your brain and that area of your brain may have had some damage from the stroke.

What are some environmental causes for urinary incontinence and their solutions?

The distance to the bathroom may be too far.

You or your caregiver may need to place a portable toilet near the bed to make it easier to urinate after naps or at nighttime.
The bed may be too high off the floor, making it hard for you to get up.
Place a bell to call for help to get out of the bed.

More Solutions for environmental problems

There is not enough lighting in the bathroom.

Provide adequate lighting in the bathroom, both day and night and leave a light or nightlight on.
Falls often happen in the rush to get to the bathroom. Do not hurry; ask for help.
Remove things that are in the way, and get rid of throw rugs

What are some behavioral causes for urinary incontinence and their solutions?

You may no longer be able to express the need to use the toilet.

Work with your caregiver to set up a regular schedule for toileting, especially on awakening, before and/or after eating, and at bedtime.
Make extra trips to the bathroom (every 2-3 hours) during the day.
Be sure that you do not feel rushed.
You may feel uneasy about performing toileting tasks and being undressed in front of another person.
If you are physically able to perform toileting tasks by yourself, once in the bathroom, ask the caregiver to step out of the room to offer privacy.
Ask the caregiver to look away or close his/her eyes, if he or she must remain in the room for safety measures.

You may have trouble undressing to go to the toilet.

Ask for help
Use clothing such as Velcro for easy removal, elastic waistbands on pants or wraparound skirts.
Be certain that you have sat or stood long enough to have used the toilet.
You may use other words or signals to express the need to go to the bathroom.
Be sure other caregivers or sitters know these words.
Have the caregiver watch for nonverbal clues such as pulling at clothing, tugging at a zipper or taking pants down.
Use these clues to encourage controlled toileting.

What Can You Do about Incontinence?

Use Adult Briefs:

There are many types of adult briefs on the market that absorb urine leaks and help prevent odor.
The purpose is to keep the skin as clean and dry as possible and to avoid skin irritation.
Adult briefs with “gelling properties” or super absorbent polymers usually hold more than fiber filled materials.
The leg of the brief should fit snuggly to avoid leakage but also be non-restrictive.
Take a toddler sized brief and insert an absorbent section of an adult brief inside for the thin person.
Some briefs have more absorbency in the front, for men, and others in the back for women.
You can choose a pad depending on the amount of absorbency you need from light to heavy. Pads can be purchased at any Walgreens or Rite Aid drugstore.
When the pad is wet, change into a new one.
Throw away the wet one in the trash; do not flush it down the toilet.

Hand washing and perineal care:

Wash your hands with soap and warm water before and after handling an adult brief.
Keeping your skin clean and dry is your best protection against skin problems.
Wash your skin after each accident, and use a little bit of powder or cornstarch to help keep your skin dry.
Remember that powder or cornstarch on the floor can make the floor slippery.
Daily washing and patting dry your perineal (per-a-nee-al) area, between your legs, from front to back will prevent a rash and decrease odors.

You may be incontinent at night:

Limit the amount of fluid you drink after supper unless there is a medical reason why you need extra fluids.
Eliminate caffeine from your diet because it may act as a diuretic (which removes fluid from the body). Drinks that contain caffeine are coffee, tea, soda pop, and energy drinks.

Use bed pads:

Disposable pads can be used to protect the bedding.
Absorbent bed pads and the combination of a draw sheet (a regular sheet folded lengthwise and tucked across the middle of the bed) and a rubber sheet (rubberized flannel baby sheet) will keep your bed dry if you have an accident.
It is easier for you or your caregiver to change the pad and draw sheet rather than the entire bed.
Stay away from plastic pants and rubberized sheets that are not shielded by a layer of cloth next to the skin.

Do Daily care:

Bathing and showering every couple of days will also help your skin stay healthy as well as changing into dry underwear when it is wet.
Remember to change your underwear every day or when it is wet.

Drink fluids:

Your body needs water every day. You need to drink 6-8 glasses of water (8 ounces each) everyday, especially when the weather is warm. Your first Instincts may lead you to decrease fluids but this can cause dehydration (too little body fluids). Drink water, Jell-O, ice cream, sherbets, and soups or broths. Soda pop and coffee should be avoided due to the caffeine and the high sugar content in soda pop. If you are unsure that you are receiving enough fluids, consult your healthcare provider.

Stay active:

Do not let a leaking bladder keep you from going places.
Pack a clean adult brief and clean underwear with you when you are out of the house.
Wear an adult brief when you leave home.

Keep a diary:

A way to schedule bladder training is with the help of a family member to remind you to go to the toilet every two hours during the day and to help you write notes in your diary.

You may need to schedule times to empty your bladder.

Before starting a schedule keep a diary of your urinating patterns for three or four days.
The information in your diary should include the time, amount of urine, for example, drops, wet (saturated pad), or bladder emptied, your activity and if you felt an urge to urinate.
Share your diary with your health care provider.

Strategies for assistance with toileting:

Devices for assistance with toileting can help you become independent in the bathroom once again.

Clothing that is easily removable for toileting (Velcro closures, elastic waistband, no buttons or zippers).
Plastic urinal for males.
Raised toilet seat.
Grab bars installed on the wall within easy reach of the toilet to help with standing up. A grab bar is a steel bar installed securely on the wall studs to allow for maximum support when held on to by the user.
Toilet safety frames to give support when standing up. A toilet safety frame is made of lightweight aluminum rails that can be easily installed to provide rigid support to make standing up and sitting down on the toilet easier.

Learn more about assistive devices for use with the toilet at Stroke Engine, a part of the Canadian StrokeNetwork (PDF).

To order assistive devices (after consultation with therapists who have done a home evaluation) online for toileting click the Patterson Medical website and click on the link, bath and toileting.

How can your health care provider help?

Discuss urinary leakage with your health care provider because it is a way of getting help with your problem.

What Information do I need to share?

If you are a female you should know if you are "leaking" when you laugh, cough, sneeze, lift something, or have a sudden strain.
Does the urinary incontinence happen at certain times during the day or night?
A diary can be helpful to pinpoint times of accidents. (An example of a voiding diary: PDF)
Know how often you usually urinate.
Is your urination painful?
Are you living in a new place?
Did the incontinence begin suddenly?
Is the incontinence occasional or constant?
Are accidents happening on the way to the bathroom?

The health care provider may order some tests of your bladder to rule out any condition that is not related to the stroke.

Medication may be used to help regain control of your bladder. The following are some drugs commonly used to help with bladder control: Ditropan XL (antispasmodic extended release tablets that help control urgency and frequency), Detrol reduces bladder muscle spasms, and Enablex, treats spasms of the bladder and urinary tract. Do not suffer in silence. There are ways to help the bladder leaking or incontinence problem.

Additional Resources:

For more information about urinary incontinence after a stroke, click on the following website: http://www.strokengine.ca/patient-info/urinary-incontinence-info/

For information about urinary incontinence products, click on these websites: http://www.depend.com/caring-for-others

http://www.webmd.com/urinary-incontinence-oab/urinary-incontinence-products

References:

Cerner Multum, Inc. (2007). Enablex. Retrieved from, http://www.drugs.com/enablex.html

Drugs.com. (2000-2009). Detrol. Retrieved from, http://www.drugs.com/detrol.html

Dumoulin, C. (2008). Urinary incontinence after a stroke. Retrieved from, http://www.strokengine.ca

Dumoulin, C., Korner-Bitensky, N. & Tannebaum, C. (2007). Urinary incontinence after stroke: Identification, assessment, and intervention by rehabilitation professionals in Canada [electronic version] Stroke, 2745-2751.

Hoeman, S.P. (2008). Rehabilitation nursing prevention, interventions, & outcomes (4th ed.). St. Louis, Missouri: Mosby Elsevier.

Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed.). St, Louis, MO: Elsevier Saunders.

Jacelon, C. (2011). The specialty practice of rehabilitation nursing. Glenview, IL: Association of Rehabilitation Nurses.

Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis, MO: Mosby.

Mangnall, J. (2008). Managing incontinence after a stroke. Practice Nursing 19(3), 122, 124-7.

Nazarkol, L. (2007). Continence problems following stroke. Nursing & Residential Care 9(4), 152-5.

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Managing Urinary Incontinence after Stroke